Pet Harbor Rescue & Referral, Inc.
. . . a port in the storm for northern and central Virginia's homeless Siberian Huskies and cats . . .
(703) 583-HSKY
Intake Form - Dogs
IF YOU ARE RETURNING A DOG ADOPTED FROM PET HARBOR, DO NOT USE THIS FORM. CALL (703) 583-HSKY OR WRITE info^petharbor.org (Substitute @ for ^.) TO RETURN A DOG.
NOTE: We are Siberian Husky rescue. We do not take other breeds. Before you fill out this form, please be sure you really want to place your dog. Most problems can be resolved, and passing them on to someone else does your dog no good. We would be happy to try to help your pet keep his home. Contact us at info@petharbor.org. Pets don't care how big their yard is. They care about keeping their families. Be certain giving up your pet is really what you want to do before you fill out this form. PLEASE BE HONEST. Lying does not help your dog.

The procedure is (a) we will review this form. It would help if you could send a picture via e-mail to info^petharbor.org (Substitute @ for ^.). If your dog is a possible candidate for our program, (b) you have the vet records faxed to us and (c) we will do a temperament evaluation. We then will let you know if your dog can come into our program and will work out those details with you. If your dog is signed over to us, there will be no further contact with you. At that point, the transfer is complete and final. Please understand that before you fill out this form.

What is your pet's name? If this is for more than one dog, you must do a separate form for each dog.
What is your name?
Why do you have to give up your dog?
Where did you get your dog (Please be specific. If you got your dog from a breeder, please give breeder's name and location.)?
Where are you located (city, county, state)?
What is your phone number?
 Alternate number?
What is your e-mail address, if any?
What is your dog's breed?
Is your dog purebred? NOTE: We cannot take anything but purebred Siberian Huskies at this time. If you are unsure, please indicate "Yes" and note why you are unsure in an e-mail or in the comment section.
 YesNo
Gender? MaleFemale What is your dog's age/birthday?
What color is your dog? Black & White Grey & White Red & White Solid White Other
Eye color? Blue Brown Bi-eyed Parti-Eyed (blue & brown in same eye)
Are your dog’s vaccinations up-to-date (at least rabies, distemper, bordetella)? YesNo Is your dog spayed or neutered (sterilized)? YesNo
Does your dog have any medical problems (Be specific.)?
 YesNo Is your dog housebroken?
 YesNo
Who is your dog's veterinarian?
What is the date your dog had his/her most recent heartworm test?
What is the last date your dog had heartworm preventative?
What brand was it?
Has your dog shown any signs of aggression towards anyone? YesNo Has your dog ever bitten anyone? YesNo
Does your dog get along well with all types of people (kids, women, men)? YesNo Does your dog get along well with cats? YesNo
Does your dog get along well with all other dogs? YesNo Other animals (such as livestock)? YesNo
Can you send a recent picture? YesNo Are you able to foster? YesNo
How did you find out about us?
By what date does your dog have to leave your home?
Our policy is to work with shelter animals on death row. Our goal is to save lives. We have limited space as we use foster care and do not have a shelter. We rarely have room for dogs turned in by owners. Most dogs coming from shelters require extensive veterinary work, which means lots of money. When we give up a space for a dog on death row to a dog turned in by an owner, we require a donation from the owner to offset the fact that a shelter dog space is being taken up by a dog turned in by an owner. Are you willing to make such a (tax-deductible) donation?
YesNo
If so, in what amount?
We also require that all veterinary work (vaccines, heartworm testing, any illnesses addressed and treated) be completed at the owner's expense before accepting a dog from an owner. Are you willing to have that veterinary work done and supply us with the records? If yes, we will tell you what exactly is needed and ask that you or your vet fax the records to us.
YesNo
Comments. This is where you can clarify any answers.