MSIR Online Release Form

Midwest Shiba Inu Rescue

Online Release Form

Identification:
Dog Name:        Birthdate or Age:

Sex: Male Female              Spayed or Neutered?: Yes No

Color:         UTD on shots?: Yes No

Height:     Weight:

AKC Registration:

AVID or HomeAgain Microchip #:

Background:

General Disposition:

How was the dog treated?

Where has the dog been housed?

Reason for release to MSIR:

Other information:

Personality, Attitude & Tendencies:
Favorite activities, play activities, and toys:

How interacts with children:

How interacts with adults:

How interacts with veterinarian:

How interacts with other dogs:

How interacts with cats:

Prefers to be: Alone With Humans With Other Dogs
How responds to nail clipping:

How responds to loud noises:

How responds to bathing:

How responds to grooming:

How responds to house visitors:

How responds to yard visitors:

Tends to:    Chew household items    Mouth when playing    Run off leash    Dig
                    Bark or be noisy    Jump on objects    Jump on people     Bite*
other tendencies:
*If bite is marked, describe incidents in detail, including dates and people/animals involved:

Training:
Housebroken Crate Trained Leash Trained Allowed on FurnitureAllowed on Bed
other training:

Obedience Training (Commands):
Sit     Down    Up-sit    Come    Stay     Heel     Halt
Fetch    Off    Leave-it     No    Eat    Nice    Over

Diet:
Food: Processed    Raw        Feedings/day:      Amount:
Brand of food:
Restrictions:
Danger:

Veterinarian:
Name:
Phone:
Address:

Medical History:
Heartworm preventative (date and brand):
Flea and tick prevention (date and brand):
Heartworm test (date and results):
Rabies Shot (date):     DHLPP Shot (date):
X-Ray certification:
Health history:

Knees/hips:

Allergies:

Congenital defects:

Other health information:

Ownership History
Breeder Name:
                Phone:
                Address:
Previous Owner #1:
                Phone:
                Address:
Previous Owner #2:
                Phone:

Address:

Ownership Release

I certify I am the owner of the above described dog, and do hereby release my ownership rights to this representative of MSIR.

Name: Date:

Phone: Email:

Address:

Created on 9-Dec-04 by: Jeni