Where did you acquire this dog?
If another shelter/rescue please list group’s name, state, city
Dog's date of birth or Age
Description/ Color & Markings:
Last time this dog went to the vet:
Does this dog have any health issues or old injuries?
Is this dog on any medication or supplements?
Is this dog on a special diet or have dietary issues?
When is this dog usually fed?
What BRAND and flavor/name of food was the dog fed?
Does the dog have any favorite toys or activities?
This dog is accustomed to:
Where has this dog been allowed?
How much time was the dog kept... (in hours)
Where did you leave the dog when no one was home?
How many hours per day on average does this dog spend unsupervised?
Where is this dog used to sleeping?
What ages of people lived with this dog?
If you checked the box that indicates that the animal has lived with children, please answer the following two questions:
What are the ages of the children?
How would you describe the dog's behavior around children?
How would you describe your household?
What type(s) of training has this dog had?
Does the dog know how to?
Has this dog ever bitten, snapped, or growled at anyone?
Number of times, Describe the situation(s):
Does this dog have any bad habits a new owner should be aware of?
Do you feel this dog is over protective?
Does this dog chase anything?
Is this dog frightened of anything?
This dog DOES get along with the following animals?
Add any relevant details:
This dog DOES NOT get along with the following animals?
Add any relevant details:
If there is an issue with dogs do you noticed a pattern?
What other animals has this dog lived with peacefully?
When leashed, does the dog lunge...
If yes, how high is it and what is the fence made of?
If your yard is not fenced how do you keep the dog confined to your property?
Has the dog repeatedly escaped from your yard?
If yes, how has the dog escaped?
If yes, when does the dog escape?
Is the dog house/potty trained?
Is the dog crate trained?
If there are potty issues has the dog seen a vet to rule out a medical issue?
How often does the dog have accidents in the house?
What kind of potty training have you tried?
Is there anything else we should know about this dog?
Do you understand that CASA charges a surrender fee to help cover the cost of care? Are you able to pay the surrender fee. ($100 Altered, $200 Unaltered) ($0 for puppies, kittens and moms)
My submitting this form, I attest that the above given information is true and to the best of my knowledge. I am the owner of the above described dog and have the legal authority to surrender/transfer ownership said dog to another party such as C.A.S.A. I give CASA permission to obtain all veterinary records related to the animal listed above. I also understand that upon surrendering this animal to CASA, CASA becomes the legal owner of this animal and will make any and all decisions regarding their being.
Staff Use Only- Scheduled/Wait times
