First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

Email*

Home Phone

Cell Phone

DOG'S NAME*

PLEASE PROVIDE DOG'S AGE. PLEASE PROVIDE DOG'S BIRTHDATE IF KNOWN*

PLEASE PROVIDE YOUR DOG'S GENDER*
Choose one: FEMALE INTACT FEMALE SPAYED MALE INTACT MALE NEUTERED

APPROXIMATELY HOW TALL IS YOUR DOG AT THE SHOULDER?*

APPROXIMATELY HOW MUCH DOES YOUR DOG WEIGH?*

PLEASE PROVIDE YOUR DOG'S BREED*
Choose one: Purebred Malinois Malinois Mix

IF YOU SELECTED MALINOIS MIX, PLEASE SPECIFY THE KIND OF MIX IF KNOWN

HOW DID YOU ACQUIRE YOUR DOG?*

IS YOUR DOG PAPERED OR REGISTERED?*

BREEDER NAME OR KENNEL NAME IF KNOWN*

DATE OF LAST RABIES VACCINATION*

DATE OF LAST PARVO/DISTEMPER VACCINATION*

DATE OF LAST LEPTOSPIROSIS VACCINATION*

DATE OF LAST BORDATELLA VACCINATION*

DATE OF LAST LYME VACCINATION*

DATE OF LAST INFLUENZA VACCINATION*

DATE OF LAST HEARTWORM TEST*

WHAT WAS THE RESULT OF THE LAST HEARTWORM TEST*
Choose one: POSITIVE NEGATIVE UNKNOWN

IS YOUR DOG ON HEARTWORM PREVENTATIVE?*

DOES YOUR DOG HAVE ANY MEDICAL CONDITIONS? IF SO PLEASE DESCRIBE THE MEDICAL CONDITION(S) AND CURRENT TREATMENT*

IS YOUR DOG MICROCHIPPED*

IF MICROCHIPPED PLEASE PROVIDE THE MICROCHIP NUMBER

WHY ARE YOU SURRENDERING YOUR MALINOIS?*

IS THERE A DEADLINE FOR WHEN THE DOG NEEDS TO BE GONE? IF SO, WHAT IS THAT DEADLINE AND WHAT IS THE REASON BEHIND THE DEADLINE?*

HAS YOUR DOG EVER BITTEN ANYONE?*

DOES YOUR DOG HAVE ANY REPORTED BITES WITH ANIMAL CONTROL OR A SHELTER?*

IF YOUR DOG HAS BITTEN, PLEASE GIVE DETAILS AROUND THE CIRCUMSTANCES AND WHETHER MEDICAL ATTENTION WAS NECESSARY*

PLEASE INDICATE IF YOUR DOG HAS EVER INJURED A PERSON OR ANIMAL. Please check all that apply *

IF YOUR DOG HAS CAUSED INJURY TO AN ANIMAL OR PERSON, PLEASE DESCRIBE THE NATURE OF THE INJURY (BITE, NIP, SCRATCH, KNOWCKED DOWN, OR HURT) AND THE CIRCUMSTANCES. {Example: kids were playing, dog intervened, person was taking a toy away, etc.} *

HAVE YOU OBSERVED ANY RESOURCE GUARDING BEHAVIOR WITH YOUR DOG? Please check all that apply*

PLEASE PROVIDE DETAILS OF RESOURCE GUARDING BEHAVIOR IF ANY WERE SELECTED ABOVE

IS YOUR DOG CRATE TRAINED?*

DOES YOUR DOG EXHIBIT SIGNS OF SEPARATION ANXIETY? Please check all that apply *

IF YOU CHOSE OTHER, PLEASE EXPLAIN *

IS YOUR DOG HOUSEBROKEN? HOW DOES HE/SHE INDICATE THAT THEY NEED TO GO OUTSIDE TO POTTY?*

IS YOU DOG GOOD WITH HANDLING AND GROOMING? Please check all that apply *

PLEASE PROVIDE DETAILS FOR ANY ISSUES WITH HANDLING OR GROOMING (Any Item Not Checked) *

IS YOUR DOG REACTIVE TO ANY OF THE FOLLOWING (Please check all that apply) *

IF YOU CHECKED ANY OF THE REACTIVITY BOXES, PLEASE PROVIDE DETAILS ON CIRCUMSTANCES AND WHAT YOU OBSERVE ABOUT THE DOG'S BEHAVIOR*

HAS YOUR DOG SPENT TIME WITH OTHER DOGS? PLEASE EXPLAIN IN DETAIL HOW YOUR DOG DOES WITH ALL SIZES, GENDERS, BREEDS OF DOGS*

HAS YOUR DOG SPENT TIME AROUND CATS OR LIVESTOCK? IF SO, HOW DO THEY BEHAVE AROUND CATS OR LIVESTOCK*

HAS YOUR DOG SPENT TIME WITH CHILDREN? IF SO, WHAT WERE THEIR AGES AND HOW DID THE DOG BEHAVE?*

HOW DOES YOUR DOG BEHAVE WHEN MEETING NEW PEOPLE AT HOME AND HOW DO THEY DO WHEN THEY MEET NEW PEOPLE OUT IN PUBLIC*

HOW WELL DOES YOUR DOG RIDE IN A VEHICLE? ARE THEY TYPICALLY RIDING FREE, TETHERED, OR IN A CRATE?*

HOW DOES YOUR DOG DO WITH FENCES?*

WHAT FOOD IS YOUR DOG CURRENTLY EATING?*

DOES YOUR DOG HAVE ANY ISSUES WITH TYPES OF FOOD AND IF SO, PLEASE DESCRIBE*

WHAT ARE YOUR DOG'S FAVORITE TREATS?*

WHAT IS YOUR DOG'S FOOD DRIVE LIKE? *

HOW MUCH PREY DRIVE DOES YOUR DOG HAVE? (PLEASE CHECK ALL THAT APPLY)*

PLEASE PROVIDE DETAILS IF YOU ANSWERED "OTHER"

HOW MUCH DOES YOUR DOG LIKE TO PLAY BALL? *

WHAT ARE YOUR DOG'S FAVORITE TOYS?*

DOES YOUR DOG ENJOY PLAYING TUG?

TRAINING

WHAT TRAINING HAS YOUR DOG HAD? Please check all that apply*

PLEASE SHARE ANY ADDITIONAL DETAILS YOU WOULD LIKE ABOUT YOUR DOG'S TRAINING

PLEASE LIST ALL COMMANDS YOUR DOG KNOWS. IF TRAINED IN A FOREIGN LANGUAGE PLEASE PROVIDE FOREIGN COMMAND AND TRANSLATION*

HAS YOUR DOG HAD PROFESSIONAL DOG TRAINING EITHER IN HOME OR BOARD AND TRAIN. Please answer 'Yes' or 'No'. IF 'Yes', PLEASE ELABORATE ON THE KIND OF TRAINING AND IF POSSIBLE, SHARE THE TRAINER OR COMPANY THAT WAS USED*

WHAT KIND OF ACTIVITIES DOES YOU ENJOY DOING WITH YOUR DOG? *

WHAT DO YOU FEEL YOUR DOG NEEDS TO WORK ON MOST?*

WHAT ARE SOME CUTE OR FUNNY OR TOUCHING STORIES ABOUT YOUR DOG?

PLEASE DESCRIBE YOUR DOG'S IDEAL HOME*

WILL YOUR DOG BE BRINGING ANY ITEMS WITH THEM SUCH AS LEASH, COLLAR, BED, TOYS, CRATE, FOOD, MEDS, ETC)*