First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone

Where is the dog located (city/state)?*

Does the dog have a name? If yes, tell us the name*

Is the dog a purebred dachshund? If no, what mix is it?*

What is the gender of the dog?

Has the dog been spayed/neutered?

How old is the dog?*

What is the dog's current weight?*

What was the last date the dog received their rabies shot?*

What was the last date the dog received their DHPP or DHLPP shot?*

Date your dog was last tested for heartworms?*

Date you gave the dog their heartworm preventative pill*

Does the dog have a microchip? If yes, please give us the number*

Please describe how their teeth look? (white, some yellow, very bad breath, etc.)*

Is the dog good with (check all that apply):

Does the dog have any medical conditions (hypothyroid, diabetes, vision problems, dental disease, etc.)*

Does the dog take any medications?*

What issues do they have? (separation anxiety, aggression, food aggression, escapes from fenced areas, digs, not housebroken, etc.)*

Reason for surrendering dog: *

Please tell us about the dogs temperament, if known.*

Is the dog potty or pee pad trained or does it still have accidents?*

Please tell us the name and phone number of the vet you use for this dog*

What date was the last time the dog was at the vet? If you don't know a date, please guess on month/year*