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Canine Intake Request Form
First Name
Last Name
Email
Phone
Street Address
City
Region/State/Province
Postal / Zip code
Country
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Why do you need to surrender the dog?
Where did the dog originally come from?
FOPAS
Rescue/Shelter
Facebook posting
Craigslist posting
Breeder
Stray
Other
If the dog came from a rescue/shelter, have you contacted them to see if they will take the dog back?
Yes
No
If the dog came from another rescue/shelter, what is the name of the rescue/shelter?
If other, please describe:
If this is a FOPAS dog, please provide the microchip number and name when adopted:
Dog's age or DOB
Dog's breed or breed mix
Dog's approximate weight
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Dog's sex
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What vetting has been completed?
Rabies
Distemper/Parvo Combo
Lepto
Heartworm Test
Heartworm Prevention
Microchipped
No vetting
Is the dog good with:
Small dogs
Large dogs
Cats
Young children
Older children
Teenagers
Women
Men
Strangers
Please describe in detail any behavior issues you've had with the dog:
Please describe in detail any medical issues the dog may have
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