BassetCARE, Inc.
Intake Form
This form is to be used by the person who physically accepts this dog in to BassetC.A.R.E.

FOSTER FAMILIES should fill out a FOSTER DOG REPORT instead of this form.  

Required fields are indicated in bold with *.
* Volunteer Name:
* Phone Number:
* E-mail:
Are you a transporter and this is a preliminary or incomplete Intake Form?   

(Fill in only those items for which you have information.)
* Date the Dog was Received by BassetC.A.R.E  (mm/dd/yy):*
Where did this dog come from?
(Shelter,Private individual)
* Name of Contact for Dog Origination:
* Address:
* Contact Phone No.
Who Transported this dog?
* Where is this dog now?
1. Dog’s Name (If known):
2. Dog’s Gender:
3. Dog’s Age (if known):
4. a) Primary color:
b) Pattern (purebred bassets are listed as tricolor or red & white, even if the “red” looks more brown or tan):

                                                                                                                           If OTHER, please describe:
5. Purebred:
6. Approximate weight of the dog:
7. House training status:
8. If you have a BassetC.A.R.E. tag for the dog, please put it on the collar and enter the tag # here:
9. Do veterinary records come with the dog?
If you do not have information, but believe the
records are somewhere else, please explain
10. Please indicate any of the following work which has been done:
(Note that if we don’t have a vet record of a shot, the shot must be re-done.)
* Distemper/Parvo Combo:
If YES, Date
* Rabies Shot:
If YES, Date
Tag #
* Bordetella (Kennel Cough):
If yes, Date:
* Tested for Heartworm/Lyme/Ehrlichia (this is usually given as one test):
If yes, Date
Dogs who test negative should be given a heartworm prevention pill ASAP.
When was this dog last given a heartworm prevention pill?     Date:
If the dog is currently at the vet, please ensure that the dog is started on prevention and that vet records are updated.
If dog has tested positive for any of these conditions, please explain:
* Spay/Neuter:
* Fecal Test:
If yes, results of fecal:
11. Please list any problems you notice with this dog:
Skin or Coat Problems:


Lameness or Other Orthopedic Problems:

Ear Problems:

Coughing or Heavy Breathing:

Bad Teeth:
Cloudy, Infected or Inflamed Eyes (be specific):
If yes, please give specific eye problem:
Please elaborate on anything to which you responded YES above:
12. Does any medication come with this dog?

                              If YES, list medication(s):
It is very important that BassetC.A.R.E. receive all relevant veterinary records.

Please send ONE copy of the record, including the ORIGINAL rabies certificate, to:
P. O. Box 1445
Oxford, NC  27565  
Fax: 757-399-1340 or 804-967-9222

Note that one copy of the veterinary records should remain with the dog at all times.
13. Based on your brief observation of this dog, pick the best description of its temperament:
If you characterized the Dog as Aggressive in the previous question, please explain:
14. General condition of dog:
15. Other Comments:
This form is to be used by the person who physically accepts this dog in to BassetC.A.R.E.