RESCUE PROGRAM
Please fill out this form honestly and completely and return to the address on the back. It is important to give a phone number.
Owner’s Name: ______________________________________________ Day Phone: _____________________________
Address: ___________________________________________________ Evening Phone: __________________________
City, State, Zip: ______________________________________________________________________________________
Best time to call? _____________________________________________________________________________________
Registered Name: _________________________________________________________________ Age: ______________
Call Name: _____________________________________________________________ Birth Date: ___________________
Sex: _______ Spayed/Neutered? ___________ Weight: _________ If unspayed female, when was last heat cycle? __________
Is there any possibility dog might be pregnant? _____________ Are AKC papers available? _________ Will you provide these to Maltese Rescue? __________ ILPH#: ___________________ Is dog co-owned? ___________ (If yes, you must provide signed release.) How long have you owned this dog? _________________Was dog bought from breeder? _____________
(If yes, give name): _____________________________________________________ Have you notified breeder about need to find new home? _____ What was breeder’s response? ______________________________________________________
Was dog bought from pet store or shelter? ____________ (If yes, give name): ______________________________________
Did shelter request that dog be returned to them? ______ Dog’s veterinarian of record: ________________________________ Are shots up to date? _______ Does dog have any physical problems? _______________________ Allergies? ____________ On medication? _____________ Will you provide health records to Maltese Rescue? ________ Has dog had obedience or any other training? _______ List commands, words, tricks, skills: ____________________________________________________ House broken? ________ Paper trained? _________ Crate trained? ____________ How does dog signify that it has to go out? ____________________________________ What brand dog food does dog eat? _______________ Dry or Canned? ______ How much does dog eat daily? ____________________________________ When? ________________________________ This dog has lived (circle all that apply): Indoors Garage Basement Dog crate/pen Fenced yard Kennel run Other: _____________________________________________________________________________________________
How does dog react to:
Other dogs? ______________________ Strangers? _____________________Children? _____________________________ Cats? ___________________________ Other animals? _________________ Alone in house? ________________________
Stormy weather? __________________ Alone in yard? __________________ Walking on lead? _______________________ Car rides? ________________________This dog is best described as (circle): High energy Happy Rowdy Active Laid back Quiet Shy Timid Other __________________________________________________________