Loyal Heart Puppy Rescue Adoption Application

Current Dog's Name	Age	Breed		Gender	Spayed/Neutered	Gets along with dogs?


Current Cat(s) Name	Age	Breed		Gender	Spayed/Neutered	Gets along with dogs?


Current Other Pet Types
If you do not have a dog, have you ever owned a dog for which you were the primary caretaker?
If yes, what happened to the dog?
Will your Rescue Dog come into regular contact with any children of any age?
Does anyone in your house have allergies to animal hair/fur/dander?
Do you own or rent your home?				How long at current residence:
If you rent, has your landlord provided written permission for you to have a dog?
Please provide your landlord's name & phone #:
* INFORMATION ON THE CARE OF YOUR DOG *
Where will your Rescue Dog be kept during the day?
Where will your Rescue Dog be kept at nighttime?
How many hours per day will your dog(s) be alone (without humans) on a regular basis?
Do you have a fenced Yard?
Is this fence adequate to safely contain a dog?
Will the dog(s) be allowed in the house?
Will the dog(s) have the free run of the house?
Are you willing to use a crate for your Rescue dog?
Will the dog(s) be kept on a runner or tied outside?
Will the dog(s) be walked daily?
Will your dog(s) receive formal obedience training?
* REFERENCES *
Who is your Veterinarian?
Vet's address:
Vet's phone number:
If you haven't been with this vet for your pet's entire life, please also provide us with your previous vet's contact information.
Who was your previous Veterinarian?
Previous Vet's address:
Previous Vet's phone number:
* MISCELLANEOUS QUESTIONS *
May we visit your home prior to application approval?
Are you aware that routine costs of maintaining a dog can be at least $500-$1000 a year?
Do you understand the state and local ordinances concerning licensing and leashing?
Have you sold, given away, or surrendered a pet to a shelter, pound or Humane Society?
If yes, please provide details?






* AGREEMENT * I attest that the Terms and Conditions of Adoption as stated in the Adoption Contract have been read in full by me and I understand that this is part of the adoption process and will be enforced. I attest that the information provided on this application is true and accurate to the best of my knowledge. I attest that I have retained a copy of the Adoption Contract and also understand that completion and submission of this application does not guarantee adoption of a Rescue dog. If filling out the application electronically, your name below substitutes for a signature.
Applicant's name:			Today's Date: M/D/YY

The dog or puppy I want to adopt is:
I am ready to adopt this dog immediately.
I understand this dog is in a southern foster home and will come to New England after adoption.
I am comfortable with a long-distance, sight-unseen adoption if I can receive extensive information about the dog from the southern foster mom.
Please Read below & initial each one. All our puppies have had three sets of DHLPP with Corona, the last one given within 2-3 days of the transport, this should protect them (there is never a 100% guarantee) from Distemper, Hepatitis, Leptospirosis, Parvo, Parainfluenza and Coronavirus, but they need two more boosters within the next 6 weeks, they have had a Bordetella vaccine to protect from Kennel Cough, but this does not prevent all strains of kennel cough any more than our flu vaccine protects against every strain of the flu- these puppies may never have been in a shelter, but if they were, they have been out of it for over 4-6 weeks. Initials:
Please understand that puppies can often be very stressed from their transport and their change in living conditions, which can compromise their immune system and between the stress and the compromised immune system, it is very common for them to get Coccidia. This is an internal parasite that can only be treated, never cured (ALL dogs in the world have this, but it lies dormant until stress triggers the parasite to multiply- easily treated). We recommend SMZ-TMP (Bactrim) along with Metronidazole OR Albon along with Metronidazole for treatment. Initials:
Another factor for puppies coming from the south to the north is climate change, again the stress from their transport and their change in living conditions, which can compromise their immune system, can lead to an Upper Respiratory Infection- again easily treated, but needs to be treated as soon as you notice a cough, sneeze, yucky eyes or a runny nose. We recommend 1) Baytril or 2) Doxycycline for the treatment of URIs. We do not have much luck with Amoxacillin and Clavamox, they seem to be more or less just a band-aid for URIs. Initials:
The health certificate is signed by a vet AFTER a physical exam is performed and there is no sign of any health issues. Most health issues require an incubation period, if anyone (canine/human/feline) is incubating for any disease there is no way to recognize that until symptoms are presenting. Initials:
It is our advice, due to climate change (south to northeast) and the possible stress from transport, that you bring your puppy (ies)/dog(s) to see your vet within three days of receiving him/her/them. Initials:
Tapeworm information- tapeworms are caused by a dog or puppy ingesting a flea carrying tapeworm. All of our dogs and puppies are Capstar'd immediately to rid them of fleas and then they are placed on flea/tick prevention- usually Frontline plus. The problem is they have usually ingested fleas before coming into rescue and then it takes time for the tapeworm to present itself. All of our dogs and puppies are wormed regularly from the time they come into rescue. The wormers we use are Strongid-C, Panacur and Ivermectin (which is also used for Heart Worm control), NONE of these wormers work on Tapeworm, but we cannot treat Tapeworm unless the animal currently has tapeworm. It is a very easy fix to rid your dog or puppy of Tapeworm, your vet will need a fecal sample, although you will already have seen the tapeworm around it's rectum, they will give you the appropriate amount of Droncit or Drontal for the weight of your dog or puppy. Initials:
All dogs over 6 months are tested for Heartworm, the tricky part with the test follows: It takes six months from the time a dog is bitten by a heartworm carrying mosquito to even have a Snap Antigen HW test show positive. e.g.: If a dog was bitten in October 2008 by a HW carrying mosquito, they would not test positive until April 2009. Microfilarae (baby heartworm) does not show on an antigen test, only adult worms show. We would need to keep an adult dog in foster care for six months, do a HW test when they come in and another six months later to be 100% guaranteed the dog was HW free. Your dog will have paperwork with the date of the HW test and the results, but there is no guarantee that a test in another few months will still show a negative result- A key factor is to keep your dog on monthly heartworm control and that will keep the microfilarae that does not show on the antigen test from developing into adult worms. Initials:
Canine Influenza information- there is no preventive vaccine for this disease and it can lead into more complicated URIs and pneumonia: http://www.marvistavet.com/html/body_canine_influenza.html Initials:
Pneumonia: http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=1758&EVetID=3001640 Initials:
Bordetella (Kennel Cough): http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=600&EVetID=3001640 Initials:
DHLPP with Corona vaccines help to protect against the following: Coronavirus: http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=2058&EVetID=3001640 Corona is caused by another species-specific virus which attacks the small intestinal lining. The symptoms of the disease include lethargy, anorexia, and depression. The sudden onset of vomiting occurs, in which blood can sometimes be found. Diarrhea is moderate to severe and is projectile. Feces is yellow-orange colored with blood and mucous occasionally found. Initials: Distemper: http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=1733&EVetID=3001640 Initials: Hepatitis: http://www.peteducation.com/article.cfm?cls=2&cat=1556&articleid=405 Initials: Leptospirosis: http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=573&EVetID=3001640 Initials: Parvo: http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=581&EVetID=3001640 Initials: Parainfluenza: http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=2165&EVetID=3001640 Canine Parainfluenza is a highly contagious respiratory disease which contributes to upper respiratory disease and Infectious Tracheobronchitis. It is one of the three major diseases that causes ITB which is also labeled "Kennel Cough." Characteristic clinical signs of CPI Infection is coughing that may be intensified by activity or excitement. Environmental factors such as drafts, colds and high humidity may enhance susceptibility to the disease. Typically, CPI is self-limiting, with a course of 5 to 10 days duration. However, secondary bacterial infection of the respiratory tract are not uncommon, and may complicate the clinical syndrome. Initials: Coccidia: http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=680&EVetID=3001640 Initials: Giardia: http://www.veterinarypartner.com/Content.plx?P=A&S=0&C=0&A=2386&EVetID=3001640 Initials:

First Name
Last Name
Street Address(No P.O.Box)
City
State/Province
Zip/Postal Code
Home Phone
Mobile Phone
Work Phone
E-mail Address

* INFORMATION ABOUT YOUR HOUSEHOLD *
Please list all the human members of your household with their ages & occupations, including yourself.
Name	Age (Yrs)	Occupation