Intake Form Your Information Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Pug Information Dog's Name * Dog's Age/Date of Birth (if known) * Breed * Why are you surrendering your dog? * Medical History Does the dog have any medical conditions we need to be aware of? * Is the dog spayed/neutered? * Yes No Unsure Is the dog current on rabies? Yes No Unsure Is the dog current on DHPP (distemper, hepatitis, parainfluenza, and parvovirus)? Yes No Unsure Veterinary Clinic Name (or Veterinarian Name) City Phone (###) ### #### Behavioral Is the dog good with people? * Yes No Selective Unknown Is the dog good with children? * Yes No Unsure Good with children above 6 years old Good with children above 10 years old Is the dog with other dogs? * Yes No Selective Unknown Is the dog good with cats? * Yes No Selective Unknown Has the dog ever bitten a human? * Yes No Unsure If yes, please explain. How is the dog used to sleeping at night? * What kind of food does the dog eat? How much and often? * Is there anything that we should know that could help during the transition? Thank you for trusting Evergreen Pug Rescue with your pug. One of our intake specialists will be in touch with you within 24 hours. If you need immediate assistance, do not hesitate to reach out to us at 425-419-6925.
