UNITED MALTESE RESCUE RELEASE/INTAKE FORM

Date:_______________

NOTE: Please send us a photo of your dog and a copy of his/her current vet records along with this form. If you prefer, you may email a photo to us in jpeg format (i.e., photofilename.jpg) to badelefine@erols.com

GENERAL

Name Of Maltese: ___________________________________________

Age: _______ Weight: ____________ Sex: M F  Neutered/Spayed Y N

Name of Owner: _________________________________

Address: _______________________________________

City: __________________________________________

State: _____________ Zip: ___________________

Daytime Phone: ____________________________

Evening Phone:_____________________________

Email:____________________________________

 

REASON FOR GIVING UP YOUR MALTESE TO RESCUE

Can you keep the dog until a new home is found? ____________

How were you referred to us? _____________________________________

Did you purchase your Maltese? Y N If no, please explain:

Is he/she AKC registered? ___________ Where did you purchase your Maltese?

Has your Maltese had other owners? _________________________________

Have you contacted the breeder? Y N Did breeder offer to take dog back? Y N

DIET

What brand of dog food do you currently feed your dog?

How much do you feed (e.g., ¼ cup, ½ cup, etc.):

How often is the dog fed/day? Favorite Treats?

TEMPERAMENT

Good with cats? ___________

Good with other dogs? _____________

Good with other types of animals? ______________________________

Good with children? ______________

Good with other adults? ____________

Any history of biting? If yes, explain:

HEALTH HISTORY:

Allergies ______

Ear Infections _______

Hip or Knee Problems _________

Eye Problems ________

Urinary Infections or Stones ________
Other

Has he/she ever been injured? _________ If so, what happened?

Are Shots Current? Y N If no, what shots are needed?

Has Maltese been Heartworm Tested? _________ If so, when? ______________ Results: Pos Neg

LIFESTYLE

Good riding in car? _____________

Ever been on airplane? ___________

Where does he/she sleep? ___________________________________________

Where is dog kept during the day? ______________________________________

Is the dog alone for long periods of time? ____________ How long? _________

Is the dog crate trained? ______________

Is the dog exercised daily? _________________________

Do you use leash or halter for walking? ______________

HABITS

Potty trained? _____________________ Outdoors? Y N Paper-trained? Y N

Does the dog: Chew __________ Dig: _________

Bark excessively___________________________

Does the dog show aggressive behavior? ______________

How does the dog react to strangers? ____________________________________

Has he/she ever been to obedience classes? _________________

BREEDING HISTORY

Has the dog been bred? Y N

If so, when/how often?

If dog is a female, did she free-whelp the puppies? Y N
How many puppies did she have?
Did any pups die? Y N  If yes, what was reason?

OTHER COMMENTS:

It is understood that United Maltese Rescue does not buy or pay for dogs. This is a service to help place Maltese dogs in new homes when their present owners can no longer keep them. This service is free, however a donation to help pay for expenses is appreciated.

PLEASE READ, SIGN AND DATE THE FOLLOWING:

I,___________________________ , hereby make available for adoption, the Maltese, named_________________________, to UNITED MALTESE RESCUE. I certify that I am the owner of this dog, free and clear of all other interests. The information I have provided about this dog is true and complete. I hereby forever release, discharge, and agree to hold harmless and indemnify the UNITED MALTESE RESCUE its Board of Directors, its members, officers, and agents from all claims, demands, actions, causes of action, or liability of any kind whatsoever arising as a result of or in connection with the adoption or other disposition of the above named dog.

OWNER'S NAME:______________________________________________

DATE:_________________________

I also agree my name and phone number may be released to the new owner of this dog. And that the new owner may contact me if he wishes, to gain any further information on this dog.

SIGNED BY OWNER:___________________________________________ DATE:__________

 

Please mail this release form to one of the following:

Lee Oden
6610 Pebble Court
Frederick, MD 21703

Barbara Fine
105 S. Jefferson St.
Middletown, MD 21769

Debbie Birtwistle
13127 Bradley Farm Drive
Oak Hill, VA 20171