Intake Release Form

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Personal Information

* First name

* Last name

* Email

* Email confirmation

Home phone

Cell number

Dog Information

*

Dog's name

*

Dog's age

*

Dog's Color

ChocolateBlackYellowSilverRed

*

Dog's sex

MaleFemale

*

Dog's weight

*

Altered status

Spayed / NeuteredIntactUnsure

*

Microchipped?

YesNo

If Microchipped, what is their chip number?

*

Intake type?

Owner / SurrenderShelter/Animal Control - owner relinquishedShelter/Animal Control - strayReturned MLRR Dog

*

Reason for surrender

Dog's Health

*

Date of last heartworm test?

*

Heartworm test results

PositiveNegative

*

On Heartworm prevention?

YesNo

*

Brand and last dose of HW prevention given

*

Rabies vaccination due

*

Rabies vaccination dose

1 year3 year

Do you have a rabies certificate? If so, please upload here.

County of your dog's rabies certificate

*

DHLPP Date

*

Lyme vaccine Date

*

Corona vaccine date

*

Bordetella vaccine date

*

Flea Treatment Date

*

Brand of Flea Treatment

Fecal test date

Fecal test results

PositiveNegative

Treatment for positive fecal?

*

List any medical concerns your dog has now

*

List Any Medications This Dog Takes

*

Veterinarian Who Performed Services (Name, Phone number)

Daily Routine

*

Brand of Dog Food

*

Feeding Time(s) daily

*

Cups Per Feeding

*

Any Supplements Given

*

Feeding Comments

Temperament

*

Please describe how your dog is with unfamiliar adults

*

Please describe how your dog is with children under 5.

Please describe how your dog is with children over 5.

*

Please describe how your dog is with unknown dogs

*

Please describe how your dog is with cats

*

Please describe how your dog is with other animals

*

This Dog Knows How To Do The Following: (Check All That Apply)

Stay/waitWalks well on a leashRetrieve Come /here Rides well in a carSitDownDrop it / release Gives pawOff / as in

*

Is The Dog Housebroken?

YesNo

*

What Are The Dog's Bathroom Signals?

*

Favorite Toy(s)

*

Please describe the exercise you are currently providing to your dog, daily

*

Training Comments

*

Known Behavioral Issues

Fear of loud noises Counter surfsJumps/climbsSeparation anxiety Barks excessively Dog aggressive Gets into house trashOpens gatesFood aggressive Chews excessively Digs

*

Has The Dog Ever Bitten Anyone?

YesNo

If Yes, Please Explain:

*

Has There Ever Been A Civil Or Criminal Complaint Filed Against You In Regard To Your Dog?

YesNo

If Yes, Please Explain:

*

Behavior Comments

Home Situation

*

Where Does The Dog Stay During The Day?

*

During The Night?

*

In Your Absence, Was The Dog Crated?

YesNo

*

How Many Hours/Day Did The Dog Spend Unsupervised/Alone?

*

What People Lived With The Dog? (Check All That Apply)

MenWomenChildren under 5yrsChildren over 5yrs

Describe Your Household

QuietModerateActive / Loud

Release

PLEASE READ CAREFULLY

I certify that I am the owner of the described dog, and I release my ownership rights to Midwest Labrador Retriever Rescue, Inc. (MLRR). I also certify that this dog does not possess of any dangerous or vicious propensities and that I have not willfully concealed information about this dog that might indicate such propensities. The information I have provided about this dog is true and complete. I understand that Midwest Labrador Retriever Rescue, Inc. may not be able to place this dog due to its age, health, physical condition, personality, lack of training, or lack of demand. I hereby FOREVER release, discharge, agree to hold harmless, and indemnify Midwest Labrador Retriever Rescue, Inc., its board of directors, officers, volunteers, members, and agents from all claims, demands, actions, causes of action, or liability of any kind whatsoever arising as a result of or in connection with the adoption or other disposition of the above described dog.

I authorize MLRR to verify the accuracy of the information I have provided.

Please sign

Signature Please use your mouse or finger (if on phone/tablet) to sign

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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