First Name*
Last Name*
Address*
City*
State/Province*
Zip/Postal Code* -
County*
Email*
Home Phone*
Work Phone* x
Cell Phone*
Alt Email
Text/Pager Email
Name of the dog(s) you are interested in*
Please list all people in the household and include ages.*
List all adult persons, age, and relationship to you living in your household (Persons name, Age, Relationship)*
List all children and their ages living in the household (Childs name, age)*
Has anyone in your household ever been convicted of animal cruelty or neglect?
Do all family adults work outside the home?
How many hours a day will the dog/s be left alone?* Choose one: none 2 3 4 5 6 7 8 9 10+
Is anyone in your household allergic to dogs?
Do you own or rent your home? If you rent you will be required to furnish a copy of your lease regarding allowance of pet.*
Will this be your first dog (as an adult)? *
Who will have primary daily responsibility for the dog (exercising, feeding, etc)?*
Are you willing to take your new dog to basic obedience training?*
Please list all pets in the household including ages and breeds: one per line*
Are all pets spayed/neutered*
If no, please explain*
Please provide the name of your veterinarian:*
Please provide phone number of current veterinirian:*
How much money do you think you will spend per year on your pet, including food, and medical care, etc.?
Have you ever given away a dog, surrendered a dog to a shelter, or returned an adopted dog to a rescue or shelter?*
If yes, please explain the circumstances*
Where will the dog be kept when you are at home?
If confined to certain areas please specify what area(s) of the house.*
Where will the dog sleep at night?
If confined to certain areas please specify what area(s)of the house.
Where will the dog be kept when you are NOT at home?
If confined to certain areas please specify what area(s) of the house.
If you will be crating the dog, how many hours a day will the dog be crated?*
Do you have a fenced in yard?
If yes, what type and what height?*
If no, do you anticipate installing one in the near future?
Please explain how you will confine the dog if not fenced.*
How do you plan to exercise your dog on a daily basis?*
What level of activity are you looking for in your dog?
What age dog are you looking for?
What size dog are you looking for?
Do you have plans to move in the foreseeable future?*
If yes, when, and what will you do with your pets?
Anything else you would like us to know?
Do you give the Healing Hearts representative permission to visit your home?*
How did you hear about Healing Hearts? Choose all that apply: This website PetFinder Adoptapet.com Facebook Other
Please note that we make every effort to insure the health of the pet, and all pets have been de-wormed and age appropriate vaccines administered. However, most of the animals come from shelter environments and illnesses can harbor for weeks. We cannot guarantee the health of the animal and if your pet shows signs of illness you will take him or her to a licensed veterinarian. By checking the box, you have read and understand this policy.
By typing your name in this space, you attest that any and all information provided is accurate and true.*
Date*
