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Owner details

Your Name:*

Today's date:*

Address Line 1:*

Address Line 2:

Town/City:*

County:

Postcode:*

Phone number:*

Best time to call the above number:*

Mobile number:

Best time to call the above number:*

Email:*

Preferred method of contact:* PhoneEmail

Dog details

Dog's name:*

Dog's breed or type:*

Dog's date or birth / age?

Male or female?

Medical history

Is the dog neutered?*

If so, when did this happen?

Date of last vaccination (please provide vaccination card if possible):

Microchip details:

Date they were last wormed:

Date of last flea treatment and name/type of product that you used:

When was the dog last weighed and what was the weight?

Any medical conditions, allergies and treatment they are or have had, including side effects?*

Which vets is the dog registered at? Please provide name and address.

Existing medical conditions

Please complete ONE of the following options. If you choose Option B) or C), you MUST fill in the boxes detailing the medical conditions and dates.

A) To the best of my knowledge and belief, this dog does not have any medical issues Yes

B) This dog has been diagnosed with the following condition: on this date:

C) This dog has has had treatment for the following condition: but is now considered cured.

Medical disclaimer

I understand that accurate completion of this form is essential to the dog's future welfare and that the information given is accurate and complete. Yes

Background

Why are you needing to rehome your dog?*

How long have you had the dog?*

Reason you got the dog*:

How many owners has this dog had?*

What brand of wet or dry food do you feed the dog, and how many times a day are they fed?*

Can you take away the food when the dog is eating, and what is their reaction?*

Who (people) lives with the dog? Please list their sex, age & personality.*

Does the dog not get on with any person they live with? If so, who and why?

How does the dog react with strangers coming into the home? Please cover the following: men, women, children over 8, children under 8.*

Are there any people outside that home that the dog does not get on with? If so, please give details.*

Has the dog ever bitten either a person/people or another animal? If yes, please give details.*

What other pets are in the home? Give as many details as possible - type, age, sex, location within the home.*

Does the dog mix well with other dogs in the home? If not, please state the dog's reaction.

Does the dog mix well with cats in the home? If not, please state the dog's reaction.

Does the dog mix well with other pets in the home? If not, please state the type of animal (e.g. rabbit) and the dog's reaction.

Does the dog mix well with dogs, cats and other animals outside the home / with other animals that they meet? Please be as specific as you can, e.g. meets dogs fine unless they are bouncy, will bark at cats, will try and chase squirrels/birds*

How long is the dog left alone for, how often and where?*

Is the dog destructive or noisy when left?*

Is the dog used to a crate?*

Does the dog have any toileting accidents in the house?*

How long is the dog walked for, how often and where?*

What is used to walk the dog? Please list all of the following that you current or have previously used and write how well the dog walked with them: collar, halti, harness type, fixed chain lead, fixed webbing lead, long line lead, extendable lead:*

Does the dog get let off the lead?*

Does the dog come back when called?*

Does the dog get on the furniture? If so. how does the dog behave when you ask it to get off?*

Can you hug the dog? If so, how does it behave?*

Can you check the dog's ears, mouth, feet, tummy and tail, and how does it react?*

Can you brush the dog?*

Does the dog play with toys? If so, do they have a favourite?*

What does the dog do when you remove their favourite toy?

Can the dog respond to "sit", "down", "stay" & "leave"?*

Has the dog been in a car? If so, how were they restrained and how did they behave?*

Does the dog get car sick?*

Other information

Is there anything else we should know about the dog?