Intake
Intake Date
-
Month
-
Day
Year
Date Picker Icon
Intake Type
Please Select
Shelter Transfer
Rescue Transfer
Stray
Owner Surrender
Status at Intake
Please Select
Adoptable
Sanctuary
Pending Behavioral Eval
Pending Veterinary Eval
Source
Source Name/Address
Please Select
Adams County Animal Shelter, 10705 Fulton Street, Brighton, CO 80601, 303 288-3294
Longmont Humane Society, 9595 Nelson Road Longmont, CO 80501, 303 772-1232
Other
Source Name
Source Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Source Phone Number
-
Area Code
Phone Number
Animal Information
Animal ID Number
Name(s)
Age or Date of Birth
Sex
Female
Male
Spayed/Neutered
Unknown
Species
Please Select
Dog
Cat
Other
Breed
Size
Please Select
X-Small
Small
Medium
Large
X-Large
Weight at Intake
Color
Coat Type
Please Select
Short
Medium
Long
Wire
Other Distinguishing Characteristics
Medical Information
Intake Condition
Medical Conditions
None
Dental Disease
Masses (benign)
Masses (cancerous)
Masses (unknown)
Blind
Deaf
Diabetic
Heart Failure
Heart Murmur (1-3)
Heart Murmur (4-6)
Missing Eye(s)
Amputee
Arthritis
Degenerative Myelopathy
Hip Dysplasia
Underweight
Overweight
Hyperthyroid
Hypothyroid
Epilepsy
Fainting/Collapsing Episodes
Allergies
Cancer
Cushings (suspected)
Cushings (confirmed)
Incontinence
Dementia
Dermatitis
Alopecia
Medical (Pre-Intake)
Vaccinations
Microchip
Exam (Veterinary)
Bloodwork
Dentistry
Surgery
Other
Date of Rabies
Year Due
Please Select
One Year from Given
Three Years from Given
Other
Date of DA2PP
Year Due
Please Select
One Year from Given
Three Years from Given
Other
Date of Other Vx
Year Due
Please Select
6 Months from Given
One Year from Given
Three Years from Given
Other
Microchip Number
Microchip Registry
Med. Records (Pre-Intake)
Medical Plan:
Behavioral
(Pre)Intake Observations
Behavior Plan:
Good with:
Small Dogs
Large Dogs
Calm Dogs Only
Cats
Small Animals
Children
Bite Record?
Yes
No
Submit
Should be Empty: