Date: _______________________   

DOG INFORMATION:

Sex: M/F    Altered: Y/N    AKC#__________________________

Dog's registered name:______________________  

Call name:_________________________________

Age:  ______________________ Date of birth: ___________________

OWNER INFORMATION:

Name of person surrendering dog:______________________________________  

Home phone: ___________________________  

Work phone:  _____________________________

Address: __________________________________________________________

_________________________________________________________________

How long have you had the dog?  ________

Your reason for surrendering the dog


BREEDER INFORMATION:

Was the breeder contacted? _______

Breeder's response __________________________________________________

Breeder name _____________________________ Phone ___________________

HEALTH RECORD:

Veterinarian _______________________________ Phone ___________________

Address ____________________________________________________________

Date of last vaccinations:_________ Rabies _________ Heartworm check ________      

Is the dog currently on heartworm preventative? ____________

Health problems _____________________________________________________

PREVIOUS HABITAT:

        Inside:  House ____ Apartment ____ Fenced Yard ____ Dog Door ____

        Outside:   Chained ______ Fenced Yard ____ Dog Run ____ Ran Loose ____

House trained: Y/N    Crate trained: Y/N    Leash trained: Y/N    Barker: Y/N

Rides well in car:  Y/N     Digs: Y/N     Dog aggressive: Y/N     Jumps fence: Y/N 

Destructive in house: Y/N    Only When Alone Y/N    Anytime Y/N

MISCELLANEOUS:

Type of dog food:__________________  Feeding per day: AM___ PM___ both___

Who fed the dog:  ___________________________________________________

Current family members and ages

____________________   _____             ____________________    _____

___________________    _____             ____________________    _____

Does the dog dislike: Men Y/N    Women Y/N    Children Y/N    Dogs Y/N    Cats Y/N

Has the dog e?er attacked another animal:  Y/N    If so, what were the circumstances:

Has the dog ever bitten anyone?  Y/N    If so, what were the circumstances:


Has the dog ever attempted to bite anyone?  Y/N   

If so, what were the circumstances:


LIVING WITH THE DOG:

Has he had run of the house ? ________  Allowed on furniture ? _________

Where did he sleep ? ______________   Does he have dog bed ? _________

Does he know any obedience commands ? ________________________________

Does he have any fears ? ______________________________________________

Does he talk or growl ? ______ Under what circumstances ?___________________

What does he enjoy most ?_____________________________________________

Is there anything the new owner should not try with the dog ? ________________

Is there anything you don't like about the dog ? ____________________________

Please supply any records you have on the dog such as pedigree and vet records

Rescue does not buy or pay for dogs. This is a service to help place Airedales in new homes when their present owners can no longer keep them. This service is free, however a donation to help pay for expenses is appreciated.