Intake Questionnaire

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Submittable Intake Questionnaire

Printable Intake Questionnaire

Owner Information

Name

Home Phone

Address

Cell Phone

City/State/Zip

Email Address

Your Boxer's Identifying Information

Name

Ears

Date of Birth / Age

Tail

Gender

Tattooed or Microchipped

Color

Tattoo or Microchip Number

Your Boxer's Medical Information

Spayed or Neutered?

Date of Spay or Neuter

Date of Last Heartworm Test

Results

Brand of Heartworm Preventative

Date of Last Dost

Brand of Flea and Tick Preventative

Date of Last Dost

Date of Last Rabies Vaccination

Vacination Type

Date of Last DHLPP Vaccination

Date of Last Bordetella Vaccination

Date of Last Lyme Vaccination

Any Other Vaccines Given?

Date of Fecal Exam

Results

Please list your Boxer’s major medical conditions and/or surgeries

Please list any other medications that your Boxer is currently taking

Does your Boxer have any allergies? If so, please explain

Your Boxer's Veterinarian Information

Name

Office Phone

Address

Office Fax

City/State/Zip

Email Address

Other Information About your Boxer

Where did you acquire your Boxer?

How long have you owned your Boxer?

Why do you need to re-home your Boxer?

What type of home do you feel would best suit your Boxer?

Is your Boxer housebroken?

Is your Boxer crate trained?

Has your Boxer lived with children?

Age(s)

Is your Boxer good with small children?

Has your Boxer lived with other dogs?

Is your Boxer good with other dogs?

Has your Boxer lived with cats?

Is your Boxer good with cats?

Does your Boxer like to ride in a car?

Can your Boxer jump fences?

Is your Boxer a digger?

Can you disturb your Boxer when eating?

Can you disturb your Boxer when sleeping?

Can you take a toy or bone away from your Boxer?

Does your Boxer guard any persons or objects?

Please describe your Boxer's personality and temperament

Please list the activities that your Boxer dislikes

Has your Boxer had any formal obedience training? If so, please provide details

Has your Boxer been protection trained? If so, please provide details

Please list the commands that your Boxer knows and responds to

What brand/type of dog food does your Boxer eat?

How much do you feed your Boxer at each meal? How many times a day?

What kind of treats does your Boxer like?

Where does your Boxer stay when alone?

Where does your Boxer sleep?

Is your Boxer shy or afraid of anything? If so, please provide details

Does your Boxer have separation anxiety? If so, please provide details

Does your Boxer have any behavior issues? If so, please provide details

Is your Boxer destructive? Is so, please provide details

Is your Boxer aggressive? If so, please provide details

Has your Boxer ever fought with another dog or animal? If so, please provide details

Has your Boxer ever bitten, nipped or snapped at a person or other dog? If so, please provide details

Please provide any other information that you think we should know about your Boxer

By Submitting this form, I certify that the information provided on this form is true and correct. I understand that by providing this information, I am under no obligation to relinquish my Boxer to NLBR nor is NLBR under any obligation to accept my Boxer.

Intake Questionnaire

Owner Information

Your Boxer's Identifying Information

Your Boxer's Medical Information

Your Boxer's Veterinarian Information

Other Information About your Boxer

Recent News @ New Life Boxer Rescue

Intake Information

Additional Links

Quick Contact Form

Intake Questionnaire

Owner Information

Your Boxer's Identifying Information

Your Boxer's Medical Information

Your Boxer's Veterinarian Information

Other Information About your Boxer

Recent News @ New Life Boxer Rescue

Intake Information

Additional Links

Quick Contact Form

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