Safe Haven of Iowa County

First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Home Phone*

Can we text that number?*
Choose one: Yes No

What is the name of the animal(s)?*

What breed is the dog?*

What is the gender of the animal(s)?*
Choose one: Male Female Multiple

What is the approximate age or birthdate of the animal(s)?*

Is/Are the animal(s) spayed or neutered?*
Choose one: Yes No Unknown

If this is a request for puppies, do you have the mother?*
Choose one: Yes No N/A

If you don't have the mother, why not?

If yes, are you willing to get the mother spayed? (Safe Haven can provide assistance if needed).*
Choose one: Yes No N/A

Did you get the animals(s) from a rescue group?*
Choose one: Yes No

If yes, what is the name of the rescue group?

If yes, have you contacted that rescue group, since most rescues ask you in their contract to return the animal to them if it is necessary to give him/her up?

Where and how did you get the animal(s) if it wasn't from a rescue group?

How long have you had him/her?*

Is the animal up to date on the rabies vaccination?*
Choose one: Yes No

Is the animal up to date on the distemper vaccination?*
Choose one: Yes No

Is the animal up to date on Heartworm medication?*
Choose one: Yes No Unknown

Is the animal up to date on flea and tick preventative?*
Choose one: Yes No Unknown

Have you observed any eye or nasal discharge?*
Choose one: Yes No

Have you observed any coughing or sneezing?*
Choose one: Yes No

Have you observed frequent urination or thirst?*
Choose one: Yes No

Have you observed frequent itching?*
Choose one: Yes No

Does the animal require a specialty diet or have dietary restrictions?*
Choose one: Yes No

If yes, please explain

Has the animal been on any medications in the last 12 months?*
Choose one: Yes No

If yes, please explain

Has the animal had any medical concerns in the last 12 months?*
Choose one: Yes No

If yes, please explain

Has the animal had any behavioral concerns in the last 12 months?*
Choose one: Yes No

If yes, please explain

Has the animal bitten another animal?*
Choose one: Yes No

If yes, did the bite require medical attention?*
Choose one: Yes No N/A

Has the animal bitten a person?*
Choose one: Yes No

If yes, did the bite require medical attention?*
Choose one: Yes No N/A

Does the dog(s) get along with other dogs?*
Choose one: Yes No Unknown

Does the dog(s) get along with cats?*
Choose one: Yes No Unknown

Why are you needing to rehome the animal(s)?*

Have you contacted any other shelters/rescues about this request?*
Choose one: Yes No

This questionnaire will be sent to the board upon completion. You should received an automatic response from adoptions@wesavepets.com requesting a photo and vet paperwork. Once that is received the board will make a decision, typically within 72 hours

We may need time while we work on opening up space at the shelter or in a foster home. Are you able to wait?*

We require a current heartworm test which is negative in order for us to take a dog. We accept either your veterinarian's recent test results or, if you choose to do so, you may come to the building on the scheduled intake day when our vet will be here and wait the 15-30 minutes it takes to have the test done. We would appreciate a donation of at least $25 for each dog to cover the cost of the test material. If the test is negative, we would accept the dog that day (unless we have discussed a later date for intake with you). Do you agree to have your dog tested? *
Choose one: Yes No

We require a socialization assessment by our veterinary team to determine the dog is safe to handle and will be able to be cared for at Safe Haven. Do you agree to having our vet team assess your dog? *
Choose one: Yes No

Do you have any connections or history with Safe Haven? Examples would be volunteer, supporter, adopter, family connection, etc.*
Choose one: Yes No

If yes, please explain.

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