Intake Requests

Contact Information

Name *

First

Last

Email *

Home phone: *

Cell phone: *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Dog Information

Dog's name: *

Date of birth (or approximate): *

Gender: *

Male
Female

Breed or mix: *

Approximate weight: *

Small (0-30 lbs)
Medium (31-50 lbs)
Large (51-80 lbs)
X-Large (81 lbs + over)

Is the dog spayed/neutered? *

Is the dog tattooed? *

If yes, please provide the tattoo #:

Is the dog microchipped? *

If yes, please provide the microchip #:

Please state the reason you are surrendering this dog: *

How long have you had this dog? *

Where did you get the dog? *

Breeder
Rescue or shelter
Found as stray
From previous owner

If from a breeder or rescue/shelter, please provide the name:

Behaviour Information

Please select if the dog currently lives with the following:

Other dogs
Cats
Kids

Compatibility with other dogs: *

Good
Fair
Poor
Unknown

Provide more information on the behaviour with other dogs if possible:

Compatibility with cats: *

Good
Fair
Poor
Unknown

Provide more information on the behaviour with cats if possible:

Compatibility with kids: *

Good
Fair
Poor
Unknown

Provide more information on the behaviour with kids if possible:

Please select any of the behaviours the dog has shown: *

Chewing
Jumping up
Nipping/teething
Fear or nervousness
Separation anxiety
Human reactivity
Other dog reactivity
Cat/small animal reactivity
Resource guarding (over food/toys/people)
None of the above

Has the dog ever shown aggressive behaviour? Please explain: *

Has the dog ever bit a person or other animal? Please explain: *

Training Information

Is the dog kennel trained? *

Yes
In training
No

Is the dog housebroken? *

Yes
In training
No

Please list commands the dog knows:

Health Information

Current food (brand and protein): *

Does the dog have any allergies? *

If yes, please list the allergies:

Please list any past injuries or illnesses: *

Does the dog require any medication(s)? *

If yes, please list the medications:

Has this dog been vaccinated? *

If yes, please list which vaccines (DA2PP, Rabies, etc):

Which veterinary clinic can we access health records at?

Dog's Photo

Please upload up to five (5) clear and well-lit photos of the dog you are requesting intake for.

Note: If your uploads do not work, please email photos to intake@manitobaunderdogs.org.

File Upload

Click or drag files to this area to upload. You can upload up to 5 files.