Placement Questionnaire

Completing this form does not guarantee Furry Friends Network will be able to place your dog/cat in our foster program or give assistance in helping to rehome your animal. This form will allow Furry Friends Network to assess your pet’s background, personality and needs. A time will be scheduled for us to meet your pet should the review of this form determine that is necessary.

Once you have submitted this form you will need to send a few digital pictures of your animal (standing, sitting, etc.). Please make sure that the pictures are no larger then 200k in file size. Email them to FurryFriendsInfo@verizon.net with the following in the subject line (Your Name, Animal's Name and the words PLACEMENT QUESTIONNAIRE).

Please note, Furry Friends Network will consider Owner Surrendered animals only from the Central Pennsylvania area.

*Someone will contact you within 48 hours once the questionnaire and pictures are received.*

You may use the tab key to navigate through the form.

GENERAL ANIMAL INFORMATION

Animal’s Name:
Species: Dog Cat
Breed:
Color/Markings:
Age (provide date of birth if known):
Weight:
Gender: Male Female
Altered (spayed/neutered): Yes No Date of surgery:
Current on Vaccines: Yes No
Heartworm Preventative given monthly: Yes No
Declawed: Yes No

BACKGROUND INFORMATION ON ANIMAL

Please describe fully why you want to rehome your animal?

Where did you get your animal?

How long have you had the animal?

If you adopted from someone else, explain why they gave up the animal to you?

Is this animal in any physical danger at this time? (Explain)

What is the maximum time you can continue to keep the animal?

What brand and variety of food do you feed your animal (i.e. Purina ProPlan Chicken and Rice Adult)?

How much and how often is your animal fed?

Is this animal completely housebroken/litter trained, if has accidents how often? (Explain)

Has your cat ever gone to the bathroom outside of the litter box? (Explain)

Is your animal kept outside? If so, where?

Is your dog crate trained?

MEDICAL HISTORY

Please describe any existing or resolved medical conditions. Please note if this animal has been used for breeding purposes, had major surgery (other than sterilization), or been diagnosed with any hereditary diseases:

When was this animal last seen by its Veterinarian (please note reason for visit)?

Date of most current Rabies vaccination?
State in which most current Rabies vaccination was given:
Date of last Distemper Combination vaccination?
Date of last Bordetella (Kennel Cough) vaccination?
Date of most current Lyme Disease vaccination?
Date of most current Heartworm/Lyme test? Results?
What brand of Heartworm Preventative do you use?
What brand of Flea Preventative do you use?
On what date was the last Heartworm and Flea Preventative given?
Date of last Feline Leukemia vaccination?
Date of last Feline Leukemia/Feline Aids test? Results?
What medications or supplements is your animal currently taking? (Explain)

Vet Name:
Address:
City: State: Zip:
Phone:
Fax:
Do you give permission for one of our volunteers to contact your vet? Yes No

**Please note a complete medical history needs to be given to Furry Friends Network at the time of the animal surrender**

TEMPERAMENT

Has your animal ever bitten someone or attempted to bite someone? (Explain)

Does your animal growl or act aggressively at people or other animals? (Explain)

Has your animal ever been socialized with/lived with small children, and how does your animal react to them?

Has does your animal react to other dogs, cats and small animals (please note any aggression)?

How is your animal in the car?

Does your animal let you trim its nails? Yes No
Does your animal let you touch its feet, face and belly? Yes No
Does your animal have any formal obedience training? Yes No
What is the highest level of formal obedience training you have completed with your animal? (Explain)

Does your animal have any issues sharing its toys with other animals or humans? (Explain)

Does your animal have any issues with animals and humans walking by or being in close proximity when it is eating?

How active is your dog? (Explain)

Is your animal destructive? (Explain)

How does your animal walk on a leash?

Does your animal have any fears (ex. Lightening, loud noise, being alone)? (Explain)

Please describe any special likes or dislikes you feel will be beneficial for Furry Friends Network to be aware of in placing your pet:

Where is your animal kept when you are not home?
Where does the animal sleep?
What other types of animals are in your home?

What are the ages of the people living in the house?
How do you exercise your animal (note the amount of time the animal is exercised each day)?

Is your yard fenced (please note type of fence)?

CONTACT INFORMATION

* Form completed by:
Relationship to Animal:
* Address:
* City: * State: * Zip:
Home Phone:
Work Phone:
Cell Phone:
* Email Address:

OWNER'S INFORMATION (IF DIFFERENT FROM ABOVE)

Owner's Name:
Co-Owner's Name:
Address:
City: State: Zip:
Home Phone:
Cell Phone:
Email Address: