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Midwest Shiba Inu Rescue - Intake Questionnaire
Please fill out this form if you are interested in surrendering your Shiba Inu to MSIR. Fill out each question completely as it helps us to best assess the needs of your dog. Contact intake@shibarescue.org with any questions.
Who is the owner of the dog?
*
Dog's Name
Dog's Age
Dog's Birthdate (if known)
Dog's Sex
Male
Female
Dog's Color
Is dog spayed or neutered?
Yes
No
Is dog up-to-date on vaccinations?
Yes
No
Has the dog been given flea and/or heartworm prevetatives?
Yes
No
Dog's AKC Registration Number
Dog's Microchip Number
Background Information
Describe dog's general disposition
How was the dog treated?
Where has the dog been housed?
Reasons for surrendering dog
Additional information
Personality, Tendencies and Attitude
Favorite activities, play activities, and toys
How does the dog interact with children?
How does the dog interact with adults?
How does the dog interact with the veternarian?
How does the dog interact with other dogs?
How does the dog interact with cats?
Dog prefers to be
alone
with humans
with other dogs
How does the dog respond to nail clipping, brushing, bathing and grooming?
How does the dog respond to loud noises?
How does the dog respond to house visitors?
How does the dog respond to yard visitors?
Dog tends to
chew on household items
mouth when playing
run off leash
bark or be noisy
jump on objects
jump on people
bite*
*If bite is marked, describe incidents in detail, including dates and people/animals involved:
Additional information about personality, tendencies, and attitude
Training
Dog is
housebroken
crate trained
leash trained
allowed on furniture
allowed on bed
Describe any additional training dog has had.
Obediance Training (Commands)
Dog knows
sit
down
up-sit
come
stay
heel
halt
fetch
off
leave it
no
eat
nice
over
Describe any additional commands known by dog
Diet
Dog is fed
processed food
raw food
Number of feedings per day
Amount of food per feeding
Brand of food
Any food or treat restrictions
Veterinarian
Name of Clinic
Name of Veterinarian
Address (include city & state)
Phone Number
Medical History
Heartworm Preventative (Brand and date last given)
Flea & Tick Preventative (Brand and date last given)
Last heartworm test (date and results)
Last rabies shot (date due)
DHLPP (date due)
X-ray certification
Health History
Knee or hip problems
Allergies
Congenital Defects
Other Health Information
Owner History
Breeder Name
Address
Phone
Previous Owner #1
Address
Phone
Previous Owner #2
Address
Phone
I am the current owner of the above described dog and I have provided complete and accurate information.
*
Please select if you agree
Current Owner
*
Street Address
City
*
State
*
Zip Code
*
Nearest large city
Phone
*
Email
*
Date Time
MM
/
DD
/
YYYY
Please upload at least one current photo of your dog.
Photo
Additional photo
Additional photo