Chihuahua Rescue & Transport
Pet History/Information Form

Completion of this form is the responsibility of the CRT volunteer/volunteers who pick up and/or foster this Chihuahua.  Please supply as much information as possible about the Chihuahua being surrendered to CRT.  If this is an owner surrender, please ask the owner to provide the information.  If not, supply as much information as possible based on the circumstances of surrender.

This is a two part form.  The first part of the form should be completed by the CRT volunteer when the Chihuahua is released to CRT.  The second part of the form should be completed by the CRT volunteer prior to release of the Chihuahua to an adoptive home.  The CRT volunteer should give a copy of these forms to the adoptive home and retain a copy for CRT records.

INFORMATION - PRIOR TO RELEASE TO CRT:

Description of Chihuahua: 

Date of surrender  _____________________

Call Name ___________________________     

Breed  ____________________        Age  _____________     

Date of Birth  ______________     Sex  ________________     

Altered?     [ ]  No       [ ] Yes    

Up to date on vaccinations?   No [ ]    Yes [ ]  

If yes, provide date of last vaccinations:  ________________

Heart worm tested?  [ ]  No    [ ]Yes 

If yes, provide date and results of last test:  ______________________

On heart worm preventative?     [ ]  No     [ ]Yes

If yes, provide brand, dosage and date due:  ____________________________________

Name & address of vet available?     [ ]No     [ ]Yes 

If yes, please enter the information here:  ______________________________________

_____________________________________________________________________

Vet records provided by owner?     [ ]  No    [ ]Yes 

If yes, please attach to this form.

Please list any medical or physical conditions that CRT and the new "parents" should be aware of:

______________________________________________________________________   

______________________________________________________________________   

______________________________________________________________________   

Please list the type/brand of food the Chihuahua has been fed.  

By owner prior to release:  ________________________________________

Feeding schedule prior to release to CRT?    ___________________________

House trained prior to release to CRT?     [ ] No     [ ]Yes 

Crate trained prior to release to CRT?      [ ] No     [ ]Yes 

Travels well prior to release to CRT?        [ ]  No    [ ]Yes

Please list any information CRT should be aware of with respect to temperament, likes, dislikes, social skills (likes/does not like: dogs/cats/children/men/women, etc.).:

______________________________________________________________________   

______________________________________________________________________   

______________________________________________________________________   

______________________________________________________________________   

______________________________________________________________________   

Has this Chihuahua ever bitten anyone prior to release to CRT?      [ ]  No   [ ] Yes

If yes, please explain in detail:    _____________________________________________

______________________________________________________________________   

______________________________________________________________________   

Why is this Chihuahua being surrendered to CRT?  _______________________________

______________________________________________________________________   

______________________________________________________________________   

INFORMATION AVAILABLE PRIOR TO RELEASE TO ADOPTIVE HOME

(To be completed by Foster parent)

Call Name (if changed)    ___________________________     

Age  _____________     

Date of Birth  ______________     Sex  ________________     

Altered?    N[ ]       [ ]  Yes 

Please provide the date and attach the vet records to certify the Chihuahua was altered by CRT.

______________________________________________________________________   

Up to date on vaccinations?   [ ]  No    [ ]  Yes

Please provide the date CRT provided the necessary vaccinations.  Also, provide a list of the vaccinations received and the vet records.    ______________________________________________________________________   

______________________________________________________________________   

Heart worm tested?  [ ]  No   [ ] Yes 

Provide date and results of last test:  ______________________

On heart worm preventative?    [ ]  No   [ ] Yes 

Provide brand, dosage and date last given.

Brand    _____________    Dosage    ______________    Date last given    ___________

Provide the name and address of vet used by CRT    ______________________________

______________________________________________________________________   

Vet records provided by owner?    [ ]  No    [ ] Yes 

If yes, please attach to this form.

Vet records for treatment provided by CRT after surrender must be attached to this form.

Please list any medical or physical conditions that CRT and the new "parents" should be aware of:

______________________________________________________________________   

______________________________________________________________________   

______________________________________________________________________   

Please list the type/brand of food the Chihuahua has been fed. 

By CRT foster home prior to adoption:   ______________________________

Feeding schedule prior to release to adoptive home?    ____________________

House trained prior to release to adoptive home?     [ ]  No    [ ]  Yes

Crate trained prior to release to adoptive home?      [ ]  No    [ ] Yes

Travels well prior to release to adoptive home?        [ ]  No    [ ] Yes

Assessment Chihuahua's temperament prior to release to adoptive home.  Please list any and all behavior the adoptive home should be aware of.

______________________________________________________________________   

______________________________________________________________________   

______________________________________________________________________   

______________________________________________________________________   

A copy of this form should be left with the adoptive parents.

A copy of this form should be sent to:

____________________________________________________
Name

_____________________________________________________

_____________________________________________________
Address