Date *

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Do you have a backyard or garden? *

Yes

No

Will the animal need to climb stairs? *

Yes

No

Is an elevator available? *

Yes

No

Will the children also be involved in the care of the animal?

walking the dog, feeding, playing, etc.

Yes

No

Are other animals living in the house? *

Yes

No

Are they used to living with other animals?

Yes

No

Do all family members agree with the choice that was made? *

Yes

No

Have you considered the costs that come with having an animal? *

Yes, I understand the costs.

No, I could use some advice.

Have you considered the consequences that come with having a pet? *

Regular walks/playtime, restriction of your freedom to go whenever and where ever you want to, finding pet-sitters if you need to leave for some time, etc.

Yes, I understand.

I'm not sure.

Have you thought about a solution for situations in which you can or will not be able to take care of the pet yourself? *

For example a holiday, stay in the hospital, etc.

Yes, I have a plan.

I'm not sure.

If you want to adopt a puppy, have you realized the consequences? *

chewing everything, house training, socialization, training, puberty, etc.

Yes, I understand.

I'm not sure.

I am not looking for a puppy.

Will the animal ever be alone in the house? *

Yes

No

Are you informed about the adoption conditions? *

Yes, I am informed.

No, I need more information.

Are you informed about the home visit(s) also after the adoption? *

Yes, I am informed.

No, I need more information.

Are you informed about the potential of parasitic and bacterial diseases suc h as eishman ia, ehrlichia, filaria, babesia? *

Are you informed about the potential of parasitic and bacterial diseases such as eishmania, ehrlichia, filaria, babesia?

Yes, I am informed.

No, I need more information.