|
|
* 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:
|
|
|
City:
|
|
|
St.
|
|
|
ZIP
|
|
|
|
|
|
|
|
|
|
* Contact Phone No.
|
|
|
|
|
|
|
Who Transported this dog?
|
|
|
|
|
|
|
* Where is this dog now?
|
|
|
|
|
|
|
|
BASIC DOG INFORMATION
|
|
|
|
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:
|
|
|
|
|
|
|
VETERINARY AND SHOT RECORDS
|
|
|
|
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
|
|
|
|
|
|
|
Clinic
|
|
|
|
|
|
|
* Rabies Shot:
|
|
|
|
|
|
|
|
If YES, Date
|
|
|
|
|
|
|
|
|
|
|
|
Tag #
|
|
|
Clinic
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
* Bordetella (Kennel Cough):
|
|
|
|
|
|
|
|
|
|
|
If yes, Date:
|
|
|
|
|
|
|
|
|
|
Clinic:
|
|
|
|
|
|
|
* Tested for Heartworm/Lyme/Ehrlichia (this is usually given as one test):
|
|
|
|
|
|
|
|
|
|
|
If yes, Date
|
|
|
|
|
|
|
|
|
|
Clinic:
|
|
|
|
|
|
|
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:
|
|
|
|
|
|
|
OTHER DOG INFORMATION
|
|
|
|
11. Please list any problems you notice with this dog:
|
|
|
|
|
|
Skin or Coat Problems:
Lumps:
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.
|
|
|
|
|
|
|
|
|
