Dog Rescue Questionnaire

Note: This form can only be filled in by an SSMPR Volunteer. If you are not an SSMPR Volunteer and you have picked up a dog, please call SSMPR at 1-866-331-PINS, or email SSMPR,Inc. for assistance.

Name of Dog:

SSMPR Tag Number:

We will not list any dog on our website without an SSMPR Tag Number.

Age: Sex (M/F): Male    Female    Don't Know   

Spayed/Neutered: Yes    No    Don't Know   
    If not Spayed/Neutered, Have any plans been made:

Color:

Height (inches):     Weight (pounds):

Docked Tail: Yes    No    Don't Know   

Cropped Ears: Yes    No    Don't Know   

Shots Up to Date: Yes    No    Don't Know   
    If not, What shots have been given:

Heartworm Testing:

All dogs must be on Heartworm Preventative prior to placement.

Did the home or shelter provide documentation that heartworm preventative was given regularly?

    Yes    No   

If No,

   Has the dog been heartworm tested recently?

    No - please provide the date the dog will undergo testing:

    Yes - what was the result? Negative    Positive   
If heartworm positive, Is the dog currently under treatment: Yes    No   

Reason the Dog is in Rescue: (Please select one)

Owner surrender direct to SSMPR
Reason for surrender

Please provide name & address of previous owner

Rescue from a shelter
Reason the dog was in the shelter (if known)

Please provide name & address of the shelter

Other (Please provide details)

Tell us more about the dog:

Where is the dog currently located (please include City/State):

Health/Temperament Problems:

House-broken:

Yes    No    Don't Know

  Crate-trained:

Yes    No    Don't Know

OK with strangers:

Yes    No    Don't Know

  OK with young children:

Yes    No    Don't Know

  OK with other dogs:

Yes    No    Don't Know

  OK with cats:

Yes    No    Don't Know

  Barks excessively:

Yes    No    Don't Know

  Digs:

Yes    No    Don't Know

Any other Comments, or suggested Website bio/description for the dog:

Additional Notes to be listed on the Website: (Optional)
(This shipping and location info WILL be listed on the website bio. If you prefer not to have this online, please leave the boxes blank!)

  Can this dog be shipped?  

  Location of dog? (City)  

CONTACT DETAILS:
(NOTE: Please complete this section fully. Only the Volunteer's first name and email address will be listed online).

SSMPR Volunteers Name:

Email Address:

Location (City/State):

Contact Phone Number (include area code):

When should this dog be listed on the SSMPR Webpage:

Now

Adoption Pending.. Please give us some details (current status, potential home details, dates, etc....)

Later... If later, please state a reason and possible date for listing

Already adopted by: (Please include name and address of Adoptive Home)

NOTE:
We will not list any dog on our website without an SSMPR Tag Number.

Thank you for making a difference in the life of this little one.  May your dedication to rescuing this special pinhead be rewarded ten fold! Your form will be submitted to SSMPR Administration at SSMPR,Inc.