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 email@example.com with any questions.
Who is the owner of the dog?
Dog's Birthdate (if known)
Is dog spayed or neutered?
Is dog up-to-date on vaccinations?
Has the dog been given flea and/or heartworm prevetatives?
Dog's AKC Registration Number
Dog's Microchip Number
Describe dog's general disposition
How was the dog treated?
Where has the dog been housed?
Reasons for surrendering dog
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
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
*If bite is marked, describe incidents in detail, including dates and people/animals involved:
Additional information about personality, tendencies, and attitude
allowed on furniture
allowed on bed
Describe any additional training dog has had.
Obediance Training (Commands)
Describe any additional commands known by dog
Dog is fed
Number of feedings per day
Amount of food per feeding
Brand of food
Any food or treat restrictions
Name of Clinic
Name of Veterinarian
Address (include city & state)
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)
Knee or hip problems
Other Health Information
Previous Owner #1
Previous Owner #2
I am the current owner of the above described dog and I have provided complete and accurate information.
Please select if you agree
Nearest large city
Please upload at least one current photo of your dog.