Long Veterinary Clinic Adoption Form

Long Veterinary Clinic Adoption Form

816-635-6616
Pet You Are Interested In?
List pets name, if there is no specific pet you are interested in please write ANY.
Contact Information
Full Name:
Occupation:
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
How long at this address?:
Phone Number:

Area Code Phone Number
Best time to call?
E-mail:
Family & Housing
How many adults are in the household?
How many children? Ages of children?
What type of home do you live in?
Does anyone in the family have a known allergy to cats/dogs?

No know allergy Allergic to Cats Allergic to Dogs Allergic to Both
Please describe your household:

Active Noisy Quite Average
If you rent, please give the rules governing pets:
Landlords Name:
Landlords Number:
** By providing this information you are allowing Long Veterinary Clinic to contact your landlord **
Other Pets
What other pets do you have?
(Specific type and Number)
Are these pets up to date on vaccinations, if not why?:
Are these pets up to date on heartworm preventative, if not why?:
Are these pets spayed/neutered, if not why?
Have you ever surrendered a pet? If so, why?
Have you ever had a pet euthanized? If so, why?
Have you ever lost a pet (i.e. death, ran away, ect.) If so, why?
Veterinarian - If you are a Long Vet client just list Long Vet under Vet's name.
Do you have a regular veterinarian?

Yes No
Veterinarian's Name:
Clinic Name:
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
** By providing Long Veterinary Clinic with this information you are allowing Long Veterinary Clinic to call your veterinarian to obtain information **
About the Pet You Wish to Adopt

What is your idea of an ideal pet?
Desired Age?

No Preference Young Adult Senior
Desired Size

No Preference Small (Under 25 lbs) Medium (25 - 50 lbs) Large (50 - 100 lbs) Giant (100 + lbs)
Desired Breed(s):
Breed(s) you would not adopt:
Desired Sex:

No Preference Spayed Female Neutered Male
Willing to Adopt:

Outgoing/hyper Needs Regular Medication Needs Grooming Shy Needs Training None of These
Where will the dog/cat spend the day?
(describe)
Where will the dog/cat spend the night?
(describe)
Who will have primary responsibility for this pet's daily care?
Who will have financial responsibility for this pet?
Do you agree to provide regular health care to the pet by a Licensed Veterinarian

Yes No
How will the pets living conditions be?

Indoor Only Indoor/Outdoor Outdoor Only
When the pet goes out, how do you plan to supervise it?

Fenced Yard Free-Range Leash Walked Chain Other
Do you agree to contact Long Veterinary Clinic if you can no longer keep this pet?

Yes No
All of the information I have given is true and complete. This pet will reside in my home as a pet. I will provide it with quality food, plenty of fresh water, indoor shelter, affection, annual physical examinations and vaccinations under the supervision of a licensed veterinarian. I also understand that the application process at Long Veterinary Clinic is not based on a first come, first served bases. I understand through this process Long Veterinary Clinic may be contacting my Veterinarian on information on current and/or past pets, and that the pet for adoption at Long Veterinary CLinic WILL be placed in the home felt best suited for the animals person, medical, and energy needs.
Signature:
Date:
Should be Empty:

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Long Veterinary Clinic Adoption Form

Pet You Are Interested In?

Contact Information

Family & Housing

Other Pets

Veterinarian - If you are a Long Vet client just list Long Vet under Vet's name.

About the Pet You Wish to Adopt