First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

Email*

Cell Phone

What is the dog's name?

Birthdate or age if known*

Breed Info*

If mixed or other breed please state other breed

Sex*

Spayed or Neutered*

If microchipped, please provide vendor (i.e. Home Again, AKC) and microchip number

Where did you get the dog (rescue, shelter, breeder etc) and how long have you had them?*

Has the dog been to a vet? If so, please provide vet name and location.*

Is the dog on any medication? If so, please list along with name of vet who prescribed. *

Is dog house trained?*

Is dog crate trained?*

Is dog leash trained?*

Has dog ever bitten a human or animal? If so, please explain. *

Does the dog get along with:
Choose all that apply: Other Dogs Small Dogs Cats Other Animals (Livestock, birds etc) Men Women Children

If your dog isn't friendly with other dogs, cats, animals or humans please explain.

Does the dog have behavioral issues?
Choose all that apply: Aggression Barking Begging Digging Jumping (On people or furniture) Separation Anxiety

Anything else we should know about the dog?

Explain why you have to surrender the dog.*

By submitting this form, I hereby authorize the Doctor of Veterinary Medicine, named above, to disclose and/or release to Dane Haven, it's agents, successors or assigns, either verbally or in writing, complete information concerning his or her medical findings, treatments and records about any animals for which I have sought care and/or treatment from the so named Doctor of Veterinary Medicine. (***Please contact your vet to let them know we will be calling. They may require your permission before speaking with us. ***)