Volunteer Name:*   

Phone Number:*          Email:*

Check this box if you are a transporter and this is a preliminary or incomplete Intake Form:
(fill in only those items for which you have information)

Date the Dog was Received by BROOD:* (mm/dd/yy)

Where did this dog come from?  Shelter    Private Individual (provide details below)

                (name and contact info):*  

                    (address):* 

          (phone number):* 

    (website - optional):   

Who Transported this Dog?

Where is this dog now? 

BASIC DOG INFORMATION

1. Dog Name (leave blank if not known):  

2. Dog's Gender: Male  Female

3. Dog's Age (if known)     OR Unknown, but probably Young  Middle  Senior

4. a) Primary color:  Brown   Black   White  Red  

4. b) Pattern (purebred bassets are listed as tri-color or red & white, even if the "red" looks more brown or tan):  Tri-Color   Red & White  Other (use only for mixes)

        If OTHER, please describe:

5. Purebred:  Yes  No  Not Sure

6. Approximate weight of the dog:   In your view is the dog:  Overweight   Too Thin   About Right

7. Housetraining status:  Housetrained   Not Housetrained   No Idea  

8. If you have a BROOD tag for the dog, please put it on the collar and write the tag number here:

VETERINARY AND SHOT RECORDS

9. Do veterinary records come with the dog:  Yes  No  

If you do not have information, but believe the records are somewhere else, please explain:

10. Please check any of the following work which has been done (note that if we don't have a vet record of a shot, the shot must be re-done):

Distemper/Parvo Combo:* Yes  No

If YES, Date Clinic

Rabies Shot:* Yes  No

If YES, Date Tag # Clinic

Please put the tag on the dog if possible.

Bordetella (Kennel Cough):*  Yes  No

If YES,  Date   Clinic

Tested for Heartworm/Lyme/Ehrlichia (this is usually given as one test):*  Yes  No 

If YES, Date Clinic

Dogs who test negative should be given a heartworm prevention pill ASAP.

When was this dog last given a heartworm prevention pill?  Date

If the dog is currently at the vet, please ensure that the dog is started on prevention and that vet records are updated.

If dog has tested positive for any of these conditions, please explain:

Spay/Neuter:* Yes  No  Not Sure

Fecal Test:*  Yes  No

        If YES, results of Fecal

OTHER DOG INFORMATION

11. Please list any problems you notice with this dog:

Skin or Coat Problems:  Yes No

Lumps: Yes No

Lameness or Other Orthopedic Problems: Yes No

Cloudy, Infected or Inflamed Eyes (be specific): Yes No

Ear Problems: Yes No

Coughing or Heavy Breathing: Yes No

Bad Teeth: Yes No

Please elaborate on anything to which you responded YES above:

12. Does any medication come with this dog?  Yes  No  If YES, What medication(s):

It is very important that BROOD receive all relevant veterinary records. Please send ONE copy of the record, including the ORIGINAL rabies certificate, to: 

BROOD, Inc.
3445 Seminole Trail, Box 248
Charlottesville, VA 22911

Note that one copy of the veterinary records should remain with the dog at all times.

13. Based on your brief observation of this dog, pick the best description of its temperament:  Friendly  Aloof  Withdrawn or Depressed Skittish  Aggressive

If you characterize the Dog as Aggressive, please explain:

14. General condition of dog:  Excellent  Good  Fair  Poor

15. Other Comments.
 (if dog is no longer in your possession or will be transferred soon, please include contact name, email and phone number):

 

 

IMPORTANT:  You must click on the "SUBMIT Dog Intake Report" button to complete this form!