EXTERNAL Dog Intake Request

ANIMAL CONCERN CUMBRIA

Your title *

First Names of Main Owner *

Surname of main owner *

Address where dog lives *

Town or area *

Your Postcode *

Your email address

Confirm email

Home or landline number *

Mobile number (first mobile) *

Second mobile if you have one

Are you the legal owner of the dog *

Is the dog microchipped? *

If unsure, select "NO"

If microchipped, is the chip currently registered to you? *

Is there anyone else who may consider themseves the legal owner? *

If yes, please provide the name, address and details of that person

Is the dog subject to any legal or police investigations, prosecutions, of the following? Select any that apply *

Please select one from the menu drop down

If yes, provide details

Has this dog been imported from abroad or travelled abroad *

If yes, please give details, dates, and Pet Passport or Health Certificate

How long have you had your dog *

Where did you get your animal from (select from drop down) *

Why are you considering rehoming your pet *

What is your pet's name *

How old is the animal (please give an estimate if not known) (please specify if weeks, months or years) *

Is the dog male or female *

What breed is your dog *

What colour is your dog *

Please describe your pet a bit more

Is the animal neutered (or spayed) *

If you know it, please enter the approximate date when your pet (if female) finished her last season (heat)

If the pet is not neutered, are you able to organise neutering before they come into our care

If the dog is chipped and you have the accurate number, please add it fully

How long ago was your animal last seen by a vet *

If your pet has been under vet care, we will need you to instruct the vet who last saw the animal to share the medical history with us.

Name, address and phone number of the veterinary practice who last saw your pet

If you indicated earlier that the animal had seen a vet

Please give a brief description of any known medical history of your pet *

What brand of food do you feed the animal, and how many times a day *

You may be asked to provide 14 days' food of that brand if your animal comes into our care. This is to enable us to transition or maintain their food to avoid diarrhoea.

Please give details of any allergies the dog has to food or any other products

(This could include food, any flea or worm products, anything in the environment, any allergies that have been tested etc)

What is the maximum number of hours your pet is normally left on their own for? *

When your pet is left alone - where is this (can pick more than one)

Which of the following does your pet do when left alone (can pick more than one)

Is your pet normally allowed on furniture? *

Where does the animal normally sleep? (can pick more than one) *

Do you consider the animal to be toilet trained (clean indoors)? *

If you need to give more detail you can do so at the end of the form

Where does your dog toilet (can pick more than one) *

How the animal behaves at home *

Please select who lives in the house (you can choose as many as apply) *

For the above, select as many as apply - you can add more detail in the notes at the end of the form

What happened when strangers visit the house or knock at the front door *

for the above, please describe what normally happens

The current home where the pet lives is (can select more than one) *

If the animal goes in the garden, how do they behave *

How often and where is the animal exercised (dogs only)

How does your dog behave on the lead (can pick more than one)

How is your dog's recall and what do they respond to when you need them to come back

Please tell us more about how your animal behaves when out and about with people, traffic, other dogs, kids etc. *

This can include unfamiliar or familiar people, cars, loud noises, people or children running, busy places, being tied up outside shops etc. You can use this box for cats too.

Has the dog either bitten or badly scratched a person before *

It is important to be truthful. A yes response will not automatically mean we are unable to help.

Please select any of the following which apply (can pick more than one) *

Thank you for answering all the above - is there anything else important you need to tell us *

Which of the following would enable you to not give up the dog? *

You can choose more than one

I have read and understood the intake process and privacy policy. I understand due to the nature of rehoming, timescales are unable to be given and we will be added to your waiting list. *

Photo of your dog Second photo of dog if you have one You can upload a PDF here if needed

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