Adoptability Questionairre
for NC, SC, GA, AL

IF YOU LIVE ELSEWHERE IN THE COUNTRY,
PLEASE CONTACT YOUR STATE COORDINATOR.

Just complete this form online. Click on the Submit button at the bottom
when ready to send. It will automatically be emailed to the right people and we will respond as soon as we are able! If you don't hear a reply in a day or two, drop an email to Kathy at springerhelpnc@yahoo.com

Your name:

Email address:

Street Address:

City:
  State:
Home Phone :      
Cell Phone:      
Work Phone:    

 

Dog's Name:

Sex:

Age/Date of Birth if known:

Weight (approx):

Color/distinguishing markings:

What type of Springer?

Bench/show Field-bred Not Sure

Spayed/neutered

Yes No

Tail docked?

Yes No

Reason for Relinquishment?

I found this dog as a stray. If so, how long ago?
If you recently found this dog, just do your best to answer the questions below to the best of your ability.

Are you the original owner ?  Yes No
If not, what is the dog's history?

Vet's Name:

Vet's Address:

City/State:

Vet's Phone number:

   

Does he/she have any medical conditions?   Yes No
If so, please explain.

Date of last vaccines:

Date of last heartworm test:

Is he/she on heartworm preventative?

Yes No

Is he/she on flea/tick preventative?

 Yes No

 

  

Any history of biting? Yes No
If so, please give details.

Is the dog microchipped? Yes No
If so, what is the company and number?

Is the dog AKC registered? Yes No
Who is the breeder?

Is he/she housetrained? Yes No    Not Sure

Is he/she crate-trained?  Yes No Not Sure

Is he/she good with children? Yes No Not Sure
If so, what ages? Any other comments?

Is he/she good with other dogs?  Yes No Not Sure

Is he/she good with cats?  Yes No Not Sure

Does he/she ride well in the car?  Yes No Not Sure

Is he/she good at the groomer ?  Yes No Not Sure

Where does the dog stay during the day? 

Where does the dog sleep ? 

Any other misc comments:

Form created by
Kathy Patterson, MidSouth ESRA Co-Coordinator
springerhelpnc@yahoo.com