PET IDENTIFICATION-USE TAB KEY TO GO FROM SPACE TO SPACE

SECTION 1

Client information:

Owners name Owners email address

Owners address 

Owners Phone H w

VeterinarianVet Phone

NAMEBREED

ALSO ANSWERS TO:DATE OF BIRTHIF UNKNOWN,

HOW OLD WHEN YOU ACQUIRED IT?

 APPROXIMATE AGE?

(  )MALE  (  )   FEMALE      COLORAPPROX. WT

HOUSETRAINED?(  )YES  (  )NO   DOES IT POTTY ON LEASH OR RUN FREE?

HAS THE DOG HAD PREVIOUS OWNERS?

DID YOU GET YOUR PET FROM ?  BREEDERPET STOREANIMAL SHELTERFRIEND

OTHER?

HOW DOES YOUR DOG SPEND THE MAJORITY OF ITS TIME?

WHERE IS YOUR DOG KEPT OUTDOORS? HOW OFTEN EXERCISED?HOW LONG? MORE THAN 10 MIN 45 MIN1HR2 HR

BRIEFLY DESCRIBE HOW DOG IS EXERCISED

WHEN IS YOUR DOG FED?       AMPMBOTH

WHAT DO YOU FEED YOUR DOG?  CANNEDDRYTABLE SCRAPSTREATS

DESCRIBE THE DOGS FEEDING HABITS? FINICKY   GOOD APPETITE  VORACIOUS

WHAT ARE YOUR DOGS FAVORITE TOYS?  

WHAT SORT OF PLAY DOES YOUR DOG ENJOY MOST?  BALL PLAYCHASE GAMETUG

WHERE DOES YOUR DOG SLEEP?  BEDROOM   KENNELKITCHEN  OTHER

SECTION 2 

HAS YOUR HOUSEHOLD CHANGED SINCE ACQUIRING YOUR DOG?    YES   NO

IF YES, DESCRIBE, 

DOES YOUR DOG ENJOY CHILDREN? 

PLEASE DESCRIBE YOUR DOGS INTERACTION WITH OTHER ANIMALS IN THE HOUSEHOLD:

DESCRIBE HOW YOUR DOG BEHAVES AROUND OTHER DOGS

SECTION 3

WHY DID YOU DECIDE TO ACQUIRE A DOG?  COMPANIONFOR CHILDPROTECTION

DESCRIBE YOUR DOG'S BEHAVIOR AS A PUPPY.  ANYTHING UNUSUAL/

WHY DID YOU CHOOSE THE BREED?

HAVE YOU OWNED OTHER DOGS IN THE PAST?  YESNO

SECTION 4

DESCRIBE YOUR DOG'S REACTION TO BEING LEFT ALONE?

DESCRIBE YOUR DOG'S BEHAVIOR WHEN YOU RETURN HOME?

DO YOU USE A CRATE?  IF YES, WHEN DID YOU BEGIN TO CRATE YOUR DOG?

HOW MANY HOURS A DAY IN A CRATE? LESS THAN...5 HRS  10 HRS. 15 HRS

SECTION 5;  

HAS YOUR DOG EVER BEEN TO OBEDIENCE SCHOOL?      PRIVATE   GROUP

HOW MANY WEEKS OF TRAINING?

DOES YOUR DOG COME WHEN CALLED?SIT OR LIE DOWN ON COMMAND?

DOES YOUR DOG PULL WHEN WALKED?

SECTION 6:  

WHAT IS YOUR DOG'S MOST UNDESIRABLE BEHAVIOR?

WHEN DID YOU FIRST NOTICE THE PROBLEM?

RANK THE SEVERITY OF THE PROBLEM.    MILDMODERATESEVERE

HOW OFTEN DOES THE PROBLEM OCCUR?   FREQUENTLY  OCCASIONALLYRARELY

HAS THERE BEEN A RECENT CHANGE IN FREQUENCY OR SEVERITY?  YESNO

HAVE THERE BEEN ANY CHANGES IN THE HOUSEHOLD THAT COULD HELP TO EXPLAIN THE 

WHAT HAVE YOU DONE SO FAR TO CORRECT YOUR DOG'S BEHAVIOR PROBLEM?

WHY DO YOU THINK THE DOG IS EXHIBITING THE BEHAVIOR PROBLEM?

SECTION 7:

DOES YOUR DOG EXHIBIT ANY OF THE FOLLOWING BEHAVIOR PROBLEMS? 

                                                                                          NEVER       OCCASIONALLY    OFTEN 

HOUSE SOILING, (URINATION, DEFECATION, MARKING)                                          

EXCESSIVE BARKING OR HOWLING                                                                         

 DESTRUCTIVE CHEWING, DIGGING                                                                          

JUMPING UP ON GUESTS OR OWNERS                                                                    

MOUTHING ON HANDS OR CLOTHING                                                                       

CHASES (CARS, PEOPLE, OTHER DOGS)                                                                  

OBJECT AND FOOD STEALING                                                                                  

DOMINANCE TESTING (PUSHY BEHAVIOR                                                                 

SEXUAL BEHAVIOR TOWARD HUMANS, ROAMING?                                                 

OVERLY SUBMISSIVE OR FEARFUL                                                                           

DOES YOUR DOG EXHIBIT AGGRESSION OR THREATEN FAMILY MEMBERS?    YESNO 

DESCRIBE EPISODES OF AGGRESSION

DOES YOUR DOG OVERREACT TOWARD GROOMING /HANDLING EFFORTS?YES NO

IS YOUR DOG AGGRESSIVE TOWARD NON FAMILY MEMBERS?   YES  NO 

DESCRIBE THE DOG'S REACTIONS (GROWLS, GLARES, BARES TEETH, BARKS , BITES)UNDER THE FOLLOWING CONDITIONS:                NEVER                          OCCASIONALLY     OFTEN

WHEN EATING                                                                                    

WHEN PLAYING                                                                                  

CHEWING A TOY                                                                                 

APPROACHED WHEN SLEEPING                                                         

WHEN PUNISHED                                                                                 

WHEN PEOPLE VISIT                                                                           

WHEN VISITORS ENTER YARD                                                             

WHEN REACHED FOR OR TOUCH                                                         

WHILE PUTTING IN CRATE                                                                   

___________________________________________________________________________

SECTION 8

HOW OLD WAS YOUR DOG WHEN IT EXHIBITED THE FIRST SIGNS OF AGGRESSIVENESS?

IS THERE ANYONE WHO THE DOG IS NEVER AGGRESSIVE TOWARDS/

DOES YOUR DOG SUFFER FROM ANY PHYSICAL CONDITION THAT MIGHT EXPLAIN ITS AGGRESSIVENESS?

IS YOUR DOG MORE AGGRESSIVE TOWARD MALES OR FEMALES?

HAS YOUR DOG EVER KILLED ANY ANIMALS?

DOES YOUR DOG SHOW SIGNS OF FEAR PRIOR TO BECOMING AGGRESSIVE?

DESCRIBE THE SEVERITY OF PAST BITES:

DESCRIBE IN DETAIL THE LAST BITE INCIDENT(WHAT, WHEN, WHERE AND WHY?)

ANY ADDITIONAL COMMENTS OR INFORMATION THAT YOU THINK I SHOULD KNOW?

SECTION 9

IS IT ACCUSTOMED TO USING A DOGGIE DOOR?  (  )YES  (  )  NO PUPPY PADS?  (  )YES 

 (  ) NO

SPAYED/NEUTERED?  (  )YES  (  )NO    IF NO, WHY NOT?

MICROCHIPPED?   (  )NO   (  )YES    IF YES, MICROCHIP #

                                                                    MICROCHIP CO>

AKC REGISTERED?   (  )NO  (  )  YES     REGISTRATION #

LAST ANNUAL SHOTS?RABIES SHOT?

BORDETELLA?RABIES TAG#_

HEARTWORM TESTED ON?RESULTS?

NAME OF H/W PREVENTATIVEDUE ON

FLEA & TICK PREVENTATIVEDUE ON_

ON MEDICATION?(   )  YES   (   )NO       IF YES, FOR WHAT?

BEEN HOSPITALIZED OR TREATED FOR MAJOR INJURY?   (   )NO  (  )YES    IF YES, EXPLAIN

_

HAS YOUR PET EVER BEEN TREATED FORBACK PROBLEMSEPILEPSY

FLEASDIABETESASTHMAURINARY INFECTIONS

OTHER HEALTH ISSUES:_

WHERE WAS THIS DOG OBTAINED?

GENERAL INFORMATION

KDR WILL ACCEPT A PET ONLY IF IT IS ADOPTABLE  WITH MEDICAL TREATMENT AND /OR BEHAVIOR MODIFICATION IT CAN BECOME ADOPTABLE.  PLEASE BE HONEST WHEN ANSWERING THE FOLLOWING QUESTIONS.  THIS INFORMATION IS VERY IMPORTANT FOR US TO KNOW WHEN SEEKING A SUITABLE FOSTER HOME AND A PERMANENT HOME FOR YOUR PET BASED ON THE INFORMATION YOU GIVE US. 

HOW WOULD YOU DESCRIBE YOUR DOGS TEMPERMENT  AROUND?

OTHER DOGS?--------------------------------(   )GOOD   (   )FAIR    (  )POOR   (  )  UNKNOWN

CATS?--------------------------------------------(   )GOOD   (   )FAIR    (  )POOR   (  )  UNKNOWN

CHILDREN UNDER 5 YRS?--------------(   )GOOD   (   )FAIR    ( )POOR   (  )  UNKNOWN

OTHER CHILDREN?-----------------------(   )GOOD   (   )FAIR    (  )POOR   (  )  UNKNOWN

STRANGERS?-------------------------------(   )GOOD   (   )FAIR    (  )POOR   (  )  UNKNOWN

IF POOR, PLEASE EXPLAIN

DOES YOUR DOG DISPLAY SIGNS OF FOOD OR FEAR AGGRESSION?  (   )NO   (  )YES

IS YOUR PET PROTECTIVE OF ITS TOYS OR POSSESSIONS?(   )NO   (  )YES

DOES YOUR PET DISPLAY ANY UNUSUAL BEHAVIORAL PROBLEMS?    (ex:  self-mutilation,

hyperactivity, tail chasing, ) OR FEARS  (ex. thunderstorms, other dogs, cats, etc?)(  )NO (  )YES

IF YES, PLEASE EXPLAIN:

HAS YOUR PET HAD ANY OBEDIENCE TRAINING?  (   )NO   (  )YES

HOW DO YOU CORRECT YOUR PET WHEN IT DOES SOMETHING WRONG? ( )YELL(  ) HIT IT

(  )CONFINE TO CRATE  (  )BANISH TO BACK YARD  (  )DON'T CORRECT

(  )  IF OTHER, PLEASE EXPLAIN_

IS YOUR PET CRATE TRAINED?   (  )NO   (  )YES   HOW LONG HAVE YOU LEFT YOUR PET IN A CRATE AT ONE TIME?HOW DID IT RESPOND?

ARE THERE STAIRS IN YOUR HOME?  (    )YES   (     )NO    IF YES, DOES IT CLIMB THEM?WHERE DOES YOUR PET SLEEP?

HOW DOES IT SPEND ITS DAY?

DOES YOUR PET TRAVEL WELL IN A CAR?   (    )NO   (   )YES

WHAT BRAND OF DOG FOOD DO YOU FEED YOUR PET?

_HOW MUCH?FEEDING TIMES?

WHAT IS YOUR DOGS FAVORITE TREATS?

DO YOU EXERCISE YOUR DOG?   (   )YES  (   ) NO   IF YES, HOW?

HOW OFTEN?

DO YOU BATHE YOUR DOG?       (   )YES  (   )NO   (    ) PERFORMED BY GROOMER

IF YES, HOW OFTEN?HOW?

DOES YOUR DOG ENJOY IT?   (  )YES   (   )NO

WILL IT LET YOU CUT IT'S NAILS?   (   )YES   (   )NO   (   )PERFORMED BY VET

LIST OF POSSESSIONS TRANSFERRED WITH PET:

________________________________________________________________________

OWNERS AFFIDAVIT

I HEREBY DECLARE THAT I AM THE LEGAL OWNER OF THE ABOVE DACHSHUND OR DACHSHUND MIX AND WILLINGLY SURRENDER THIS ANIMAL TO KENTUCKY DACHSHUND RESCUE FOR THE PURPOSE OF FINDING IT A NEW PERMANENT HOME.  I UNDERSTAND I AM RELINQUISHING MY PRESENT AND FUTURE RIGHTS AND CLAIMS TO THIS ANIMAL AND ITS POSSESSIONS LISTED HEREIN WHICH ARE BEING SURRENDERED ALONG WITH THE ANIMAL TO ENSURE THE ANIMAL'S CONTINUED HAPPINESS AND WELFARE.  I UNDERSTAND THAT I MAY NOT BE PROVIDED WITH INFORMATION ABOUT THIS ANIMAL'S WHEREABOUTS AFTER ITS SURRENDER, BUT AM ASSURED IT WILL RECEIVE A LOVING AND PERMANENT HOME AND WILL NOT BE USED FOR ANY BREEDING PURPOSE OR MEDICAL OR SCIENTIFIC EXPERIMENTATION.  I FURTHER ATTEST TO THE BEST OF MY KNOWLEDGE, THIS ANIMAL HAS NO PHYSICAL OR EMOTIONAL PROBLEMS OR HANDICAPS THAT WOULD MAKE IT UNSUITABLE AS A FAMILY PET.  ALL STATEMENTS MADE HEREIN BY ME ARE TRUE AND COMPLETE TO THE BEST OF MY ABILITY.

SHELTER SURRENDER/SHELTER NAME_

OFFICER ON DUTY

OWNER surrender/ SIGNATURE

PRINTED NAME

DRIVERS LICENSE#SS#

                                                        SURRENDER FEE IS $50 FOR DOGS WHO ARE UP TO DATE ON ALL VACCINES/SPAYED

                                                           $100 FOR PETS WHO REQUIRE VACCINES/NEUTER/BEHAVIOR MODIFICATION

                                              FEES ARE NON-REFUNDABLE AND WILL BE CONSIDERED A DONATION IF YOU DO NOT SURRENDER

            MASTER CARD/VISA  (16DIGITS)EXPIRATION DATE

KDAR OFFICIAL USE ONLY

DATE OF SURRENDER-TIME

KDAR MEMBER

ADDRESS

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