EmailMe Form - Intake Form

Email photos (we prefer at least 3) of your dog to lkh5@mchsi.com.

Please call your vet and request all medical history be faxed to 609-257-6030.

Once we are able to review all information (including vet records) we will connect with you to discuss further steps and request a release be signed.

Owner Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email

Home Phone

### - ### - ####

Cell Phone

### - ### - ####

Dog age & date of birth

Dog Name

Weight

Gender

Pure bred or mix (if mix with what?)

Where did you get your dog?

How long have you had your dog?

Reason you can no longer keep your dog

Is the dog spayed/neutered?

Date of last vet visit.
Is the dog up-to-date on vaccinations? If not, please explain.

Date of last heartworm blood test and result.
Heartworm preventative used and date last given.

Flea/tick preventative used and date last given

Current Diet, amount fed and feeding schedule

Health issues – skin, allergies, ear infection, arthritis, hip/elbow dysplasia, etc. (please describe in detail)

Activity level:
High – full of energy needs to play hard, take frequent walks, always seems to be in motion, very busy in house and outdoors
Moderate – likes to play, take walks, etc but is pretty quiet in the house
Low – couch potato

Exercise – describe the type and frequency of exercise your dog is used to

Outdoor containment your dog is used to (check all that apply)

fenced yard

Tie-out or runner

Dog house

Pen/kennel area

If yard is fenced, describe your fencing.

Average time your dog spends outdoors

Is the dog house-trained?

Crate trained:
Leash skills:
Riding in cars:

Behavior with other dogs – M/F, size, breeds, etc. describe types of dogs exposed to and frequency

Behavior with cats

Behavior with children - ages of children and frequency of exposure

Food issues – is dog food protective/aggressive with other dogs, kids, adults? Please be specific

Fears – vet, thunder, loud noises, toenail clipping, etc.

Know any commands?
List

Does your dog:
(note: these are not things which will prevent a dog from being accepted, just helps us to assess needs)

Give details of above

Describe dog’s personality:

Has your dog had any formal training?
Please describe the type of training, how long your dog received training and any special areas/issues addressed in training

Describe things dog needs work on

Has your dog ever nipped or bitten a person? Or has the dog shown any type of aggressive action?
Please describe:

If accepted into our program, can you keep your dog until a suitable home is found? For how long?

We will need to meet and assess your dog prior to accepting into our program. We will ask you to bring your dog to meet us at a designated location. What days and times work best for you?

Although not required, we do appreciate a donation when you surrender your dog to help us cover costs involved in caring for him or her. Items such as your dog’s heartworm meds, flea/tick meds. Leash, etc are also appreciated. Please specify amount you plan to donate (we will prepare a donation letter for you for tax purposes)

Current Vet Name and Number
PLEASE call your vet and give your permission to release any and all information to us

In situations where the dog in need of re-homing is not in an area where J&L has volunteers, we may refer your intake request to another reputable rescue. Check "yes" to give your permission for J&L to forward your info or "no" to decline. (J&L will notify you if your information is forwarded. ) *

Yes

No

Date Time

MM / DD / YYYY

Electronic Signature

Clear

Email photos (we prefer at least 3) of your dog to lkh5@mchsi.com. Please call your vet and request all medical history be faxed to 609-257-6030.

Email photos (we prefer at least 3) of your dog to lkh5@mchsi.com.

Please call your vet and request all medical history be faxed to 609-257-6030.