RHS Intake Form with Medical (Internal only)

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Personal Information

* First name

* Last name

* Email

* Email confirmation

Home phone

Cell number

* Current Address

Current Address 2

* Zip

* City

Country

*State/Province

Date of Birth

* Month

* Day

* Year

Pet Information

What is the pet's name? (If return, what was pet's RHS name?)

Origin

ShelterOwner surrenderStrayOther

Notes on Origin

Breed(s) (if known)

Sex

MaleFemale

Approximate age or date of birth (if known)

Approximate weight:

Less than 15 lbs16 to 35 lbs36 to 70 lbsOver 70 lbs.

Is the pet microchipped?

YesNoDon't know

What is microchip number and brand (if known)?

Is the pet spayed or neutered?

YesNoDon't know

Primary and secondary coat color(s)

Medical Records

Does this pet have any known medical conditions? If so, describe.

Medical Records show that the dog IS UP TO DATE ON:

Rabies - 1 yrRabies - 3 yrDHP - ParvoBordatella LeptoHeartworm Preventative/HW TestSpay/NeuterMicrochipNone of the aboveNo medical records are available

If dog is a puppy, what shots has he/she already received and when?

Foster Info

Foster name (if known)and email address

I have read and agree to the terms and conditions. By checking this box I am confirming that I am 13 years of age or older.

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