Animal History: Dog

Date
Animal's Name *
Reason for entry	Please select from list stray surrender transfer other
If the dog is microchipped, please enter number her:
Species	Dog Cat Horse Donkey Pony Bird Rabbit Other
Gender *	Please select from list Male Female unknown
Colour	__________ Amber Black Black and Brindle Black and Brown Black and Tan Black and White Blue Blue and White Blue Merle Brindle Brindle and White Brown Brown and White Chocolate Cinnamon Cream Fawn Golden Grey Grey and White Liver Liver and White Silver Tan Tan and White Tortoiseshell and White Tricolour White Yellow and Grey
Breed *	__________ Akita American Shorthair Basset Beagle Bearded Collie Belgian Shepherd Malinois Bernese Mountain Dog Bichon Frise Bloodhound Border Collie Border Terrier Boxer Bullmastiff Bull Terrier Cairn Terrier Catahoula Leopard Dog Cavalier King Charles Spaniel Checkered Giant Chihuahua Chow Chow Cocker Spaniel Collie Corgi Dachshund Dalmatian Deerhound Doberman Pinscher English Bulldog English Cocker Spaniel English Pointer English Setter Foxhound Fox Terrier French Bulldog Golden Retriever Gordon Setter Great Dane Great Pyrenees Greyhound GSD Harrier Hound Husky Irish Setter Irish Wolfhound Italian Greyhound JRT Labrador Lakeland Terrier Leonberger Lurcher Maltese Mastiff Mixed Breed Newfoundland Dog Old English Bulldog Old English Sheepdog Other Pit Bull Terrier Pointer Pomeranian Poodle Prairie Dog Pug Retriever Rottweiler Rough Collie Saint Bernard St. Bernard Saluki Samoyed Schnauzer Scottish Terrier Scottie Setter Sheep Dog Sheltie Shih Tzu Siberian Husky Smooth Fox Terrier Spaniel Spitz Springer Staffie Terrier Tibetan Spaniel West Highland White Terrier Westie Wheaten Terrier Whippet Yorkshire Terrier Yorkie
Breed 2 if crossbreed
Description
Age (enter number only, no text) *
Age in month or years *	Please select from list Weeks Month Years
Have you got vaccination records for the animal? *	NoYes
When has the dog been wormed last? *	Please select from list recently less than 3 month ago more than 3 month ago never don't know
Has the animal been neutered/spayed? *	Please select from list Yes No Unknown
When has the dog last received a tick/flea treatment? *	Please select from list recently less than 3 month ago more than 3 month ago never don't know
Does your animal have any medical conditions that are undergoing treatment?
Has your animal had any previous operations or treatment for medical conditions?
Does your animal have any known allergies?
I consent to CAW contacting my vet and receive all details in relation to the medical history of the dog. *	NoYes
Name and Phone of Vet *
Owner's reason for parting with animal *
Has the animal lived with children?	Please select from list Yes No Not known
Please specify the ages of children and animal's behaviour
Has the animal had frequent contact with children?	NoYes
Please specify the ages of children and animal's behaviour
Is the animal comfortable around men and women?
Where did you get the animal from initially? *
How long have you had the dog? *
How would you describe your animal's behaviour? For example: bold, shy, timid, aggressive, affectionate
How does your animal react to grooming?
How does your animal behave at the vets?
Is he/she prone to biting? *
Has he/she any unusual behavioural habits?
Has the animal ever been destructive in the house? Please describe
Has the animal lived with dogs? If so, please specify age, sex and reaction
Has the animal lived with cats? If so, please specify age, sex and reaction
Has the animal lived with animals other than cats and dogs? If so, please specify
Please describe your animal's feeding regime - brands of food, scraps, dry or tinned, flavours, feeding times and quantities. Any dislikes? *
Is the dog housetrained? *
Where does the dog spend the day?	Please select from list In House outside House and outside
Where does the dog usually sleep at night? *	Please select from list outside without shelter outside with shelter in garage in utility or other small room in house in bedroom in bed
Does the animal travel well?
Can the dog be left alone for any period of time? If so, how long for and are there any issues?
How often is the dog walked? *	Please select from list several times a day once a day infrequently never
How is the dog walked?	leash on collar leash on harness off leash
How does the dog react to other dogs outside of the home, e.g. on walks?
Will the animal give up toys when commanded to?
Is there anything else you feel we should know before making a decision of taking the dog?
Are you prepared to pay a surrender fee?
Is there a particular date the dog has to go?
Person providing information	Please select from list Owner Inspector Owner's representative Other
First Name *
Last Name *
Are you over 18 years of age? *	NoYes
Phone *
Your email
Street
City *
County *
Eircode
Country	Ireland Northern Ireland UK Other
*	Please send good quality photos of the animal as we will not be able to process your application without them. Please tick the box to confirm photos are being sent
Are you happy for us to advertise the animal on social media straight away? *	NoYes