Cardigan Welsh Corgi National Rescue Trust

Rescue Dog Evaluation Form

Please answer as completely as possible, If owner turn In, please get as much info as possible Use back of sheet/ additional sheets if needed

Dogs Name______

AGE ______D.O.B. ______DESCRIPTION_ Attach picture if possible.

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Microchip -Tattoo Information______

Rescue Incoming Date: ______Received From (shelter)______

If Owner Release

Owners Name & Address______

______Phone______

Reason Dog was given up______

Dogs breeder (if known)______

______Male Neutered YES NO If NO-Appointment Date______Stitches Out______

______Female Spayed YES NO If NO-Appointment date______Stitches Out:______

Heartworm Test Date: ______Result______

If positive, treatment date: ______Status: ______

Rabies______Vet______Tag #______

VACCINATIONS / DATE / DATE / DATE / DATE / DATE / DATE
DA2PP+CVK
Bordetella
De-Worming
HWM Preventative
Flea/Tick Control

Medical History and Veterinarian information ______

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Special Medical Needs:______

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Brand- Dog Food - when - amount______

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CHARACTERISTICS

Explain as much as possible for each please

o Good with Children ______

What ages 1 – 5, 5 – 10, 10 - 12, 13 and over All ages

o Dog Aggressive________

All dog large dogs small dogs

o Good with Other Dogs ______

o Good with Cats ______

o Leash Trained ______.

o Crate/Kennel Trained ______

Does the dog sleep in a crate= at night, when no one is home,

o Paper Trained ______

o House Trained ______

o Obedience Trained ______

o People Aggressive ______

o Grooming problems______

o Has dog bitten ______

Circumstances______

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o Shy/Fearful? Please describe Circumstances______

______

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o Dogs Energy Level ______

______

o Dogs Personality______

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o Include anything that makes this dog Happy______

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Are Cardigan’s papers included with this evaluation? YES NO

If yes give the person surrendering the dog a photo copy of VOIDED Papers for their records.

Is Cardigan suitable for placement? ______if so what would be most suitable type of home______

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Evaluator’s Name & Region please print

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Signature of Evaluator Date