ACO/Shelter Surrender

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ACO / Shelter Intake Form

Submission Date

https://bones.formstack.com/forms/images/2/calendar.png

Month

Day

Year

Hour

Minute

AM/PM

Shelter / ACO (Township) Name*

Your Name*

First Name*

Last Name*

Your Full Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Street

Town:

State, ZIP

Phone*

Contact Person*

First Name*

Last Name*

Phone Cell

Contact person

Beagle Description

Dog's name or ID

Gender

Male Female

Have you scanned for microchip?

Yes No

If yes, what were the results?

Brand and number

Spayed / Neutered

Yes No Unknown

Age

Height

Weight

Color

Look

Purebred Beagle Look Beagle Mix

Other: Other Value

Notes

Medical History

Been diagnosed or treated for any medical issues or injuries?

Yes No

Please explain

Any past or current medical conditions, injuries, or allergies

Yes No

Please explain

Any touch-sensitive areas?

Yes No

Please explain

Appearance (weight, coat, eyes, fleas, ticks)

Eyesight?

Hearing?

Mobility?

any limping?

Other

Vaccinations

Rabies DHLPP Bordatella Lyme

Other: Other Value

Testing

Heartworm Lyme Anaplasma Ehrlichia

Other: Other Value

ACO / Shelter: Can you have vaccinations done?

Yes No

Other: Other Value

Name and phone number of vets that have treated the dog?

Beagle History

How long has he/she been there?

How long can you hold onto the beagle?

Where is it from? Stray or owner surrender?

Stray Owner Surrender

Why surrendered?

How long did the last owner have the dog?

Do you know where the owner got the dog?

pet store, breeder, shelter

What was the dog's previous life? (If known)

Not known House dog Hunter Tied out Kenneled

Other: Other Value

Any other information from the owner?

How is he/she reacting to kennel life?

Has the beagle been previously adopted and returned?

Yes No

Other: Other Value

Behavioral Assessment

Does the beagle get along with:

Men Women Children Male Dogs Female Dogs Cats

Does the beagle:

Guard Food / Toys Bark incessantly Chew or destroy anything in the kennel Keep a clean kennel / housetraining history Eat poop Show aggressive tendencies

Other: Other Value

Has the dog bitten anyone?

Yes No

Other: Other Value

Has the dog bitten other animals?

Yes No

Other: Other Value

Has the beagle been officially temperament tested?

Yes No

By whom?

When was it done?

Results

Please fax results to 888-288-0105

Fear of

Hands Spooks easily Loud noises Thunderstorms Other dogs / people

Other: Other Value

Escape history?

fence jumper, climber, digger, slips collar

Attitude / Friendliness

Activity Level

Hyperactive Active Middle Couch potatoe

Other: Other Value

Other characteristics:

Affectionate Aggressive Attentive Independent Confident Demanding Destructive Dominant Submissive Easy Going Fearful Friendly Reserved Gentle Happy Passive Stubborn Noisy Quiet Separation issues

Other: Other Value

Obedience Training

Does the beagle walk well on a leash?

Yes No

Other: Other Value

Does the beagle know any commands?

Sit Stay Come Down

Other: Other Value

Does he/she jump on people?

Yes No

Other: Other Value

Additional Comments

How does he/she react to correction?

Does he/she know any tricks?

Yes No

Other: Other Value

Favorite games or toys?

How does the beagle ride in a car?

By submitting this form you agree to reimburse Beagles of New England States any money spent on your dog if you decide to keep him/her.

Agree Disagree

By submitting this form, you are asking to transfer ownership of your dog to Beagles of New England States

Agree Disagree

If you are assisting B.O.N.E.S. by continuing to care for the beagle, you are responsible for daily care of the dog. You will refer all potential adopters to www.bonesbeagles.org to complete an adoption application.

Agree Disagree