Name of dog in need of rescue*
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 *
How much does this dog weigh?*
Is this dog spayed or neutered?*
Is this dog up to date with rabies vaccination?*
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?*
Is this dog good with children?
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? *
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 email@example.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?*
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 *
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. *