First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

Email*

Home Phone

Work Phone
x

Cell Phone

Alt Email

Name of dog in need of rescue*

Where did you get the dog?
Choose all that apply: Breeder Other Rescue Shelter

If other, please explain.

What is your relationship to this dog?*

Can you tell us why this dog needs to be rehomed?*

What breed/breeds is your dog?*

What is your dog's age?*

Is your dog male or female *
Choose one: Female Male

How much does this dog weigh?*

Is this dog spayed or neutered?*
Choose one: Yes No

Is this dog up to date with rabies vaccination?*
Choose one: Yes No

When is the last time this dog has been seen by a veterinarian?*

I will call my vet's office to give them permission to speak with a Pixie Mamas representative. Please initial and date. (We need your veterinarian's name and phone number. Without that information, your request cannot be processed. We need to determine legal ownership of the dog and gather any history that they have for the dog.) *

Name and phone number of Veterinarian

Does this dog have any known health issues? If so, please describe.

Has this dog bitten? If so, how many times and under what circumstances?*

Is this dog good with other dogs?*
Choose one: Yes No

Is this dog good with children?
Choose one: Age 1 - 12 years old Over the Age of 12 years old

Is it necessary to place this dog as an only dog?

Your relationship with the dog? *
Choose one: Owner Relative of owner Friend of owner Found the dog Other - if other, please explain in comments section at the end of the form

A RECENT picture of your dog is needed before we can accept him/her into rescue. Please e-mail a picture immediately after submitting this form to info@pixiemamasrescue.com . Until we receive a recent picture of your dog, your request cannot be processed. Yes, I will send a picture. Initial and date*

Is this dog safe for the time being?*
Choose one: Yes No

Comments and any other information you are able to share

By checking YES, I certify that the information contained in this application is true and correct *
Choose one: Yes No

By checking YES, I understand that if the above-referenced dog is accepted into Pixie Mamas Rescue, I will be giving up forever all rights, title, and interest to the Dog. I further understand that all future decisions regarding the placement of this animal will be made solely by PMR. I also understand that if this Dog is later found to have such an unpredictable temperament as to be unsuitable for any placement, or if the animal’s quality of life is substantially impaired, in the opinion of a competent veterinarian, by a chronic, irreversible, painful condition, euthanasia may be considered as a final alternative to adoptive placement. *
Choose one: Yes No