Peace of Mind Dog Rescue · Courtesy Listing Questionnaire

Your Information

Name

*

First Name

Last Name

Email

*

Verify Email

*

Email again

*

Please enter the same email address again

Verify Email

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Home phone

*

Cell phone

*

What is your preferred means of communication?

*

Home phone

Cell phone

Email

Text

What is the name of the legal owner of this dog?

*

What is your relationship to the dog's owner?

*

Age of the owner (not age of the dog)

How did you hear about us?

*

Other

*

Dog's Information

Dog's name

*

Breed

*

If your dog is a mix, list the one or two most prominent breeds

If you can, please supply one or two photos of your dog

Photo 1

Photo 2

Dog's weight

*

Dog's age

*

Dog's gender

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Male

Female

Is the dog spayed/neutered?

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Yes

No

How long have you had this dog?

*

Where did you get this dog?

*

Has this dog ever bitten a person?

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Yes

No

Explain

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Why are you looking to re-home this dog?

*

Guardian passed away

Guardian is ill or physically unable to care for dog

Guardian moved to nursing home, assisted living, or senior home

Dog has behavior issue

Other

Explain

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How quickly do you need a place for this dog?

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When did this dog last see a vet?

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Can you provide medical records?

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Yes

No

Please give name of the vet clinic and person's name the records are under

*

Does your dog have any current medical issues?

*

What training does this dog have?

Check all that apply

House trained

Crate trained

Walks well on leash

Basic commands

Other

Explain other training

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How does your dog get along with other dogs in general? Are there particular types of dogs your dog doesn't get along with?

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How does your dog respond to dogs when out on a walk?

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For example: ignores, politely sniffs, gets excited, barks

How does your dog respond to people he/she meets in public for the first time?

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How does your dog respond to new people who come to the house?

*

How does your dog respond to children?

*

How does your dog respond to cats?

*

What is your dog's energy level?

*

For example: calm, needs a lot of exercise, doesn't have a stop button, settles at home nicely

How does your dog respond if you try to take away a bone, food dish, or favorite toy? Does he/she growl or snap?

*

Where does your dog sleep at night?

*

Is your dog indoors or outdoors during the day? How many hours is he left alone on a typical day?

*

How does your dog respond to being left at home?

*

For example: needs to be crated, vocal, calm

Is there anything else you would like us to know about your dog or your situation?

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