Intake Questionnaire - Danes in Distress

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- Surrender Procedure
- Intake Questionnaire
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Home
What’s Happening
Adoptions
Surrenders
- Surrender Procedure
- Intake Questionnaire
Help Danes
Contact Us

Intake Questionnaire

admin2023-07-13T17:26:31+00:00

Step 1 of 7 - Section 1 - About You

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PLEASE NOTE WE ONLY ACCEPT SURRENDERS IN ONTARIO CANADA

The Surrender Intake form is separated into 7 stages. Each stage will be verified for required answers before proceeding to the next section.

Your dog will be placed much sooner if you can supply photograph(s). Total size must be less than 1 Mb per picture and the picture format must be jpeg (.jpg). Please, no humans in the photographs!

If you do not know the answer to a question, just answer N/A. If multiple choice questions don't show the answer you want, you can enter further explanation in the 'Additional Comments' at the end of the form.
Your Full Name:*
First Last
Do you have an email address:*
- Yes
- No
Email:*
Enter Email Confirm Email
Primary Phone:*

Enter only numbers - e.g. 555 555 5555.
Cell Phone:

Enter only numbers - e.g. 555 555 5555.
Business Phone:

Enter only numbers - e.g. 555 555 5555.
Street Address:*
City:*
Province:*
Select your Province
Postal Code:*
Closest major City:

Answer this if you live in a rural community.
How did you hear about Danes in Distress:

2 - About the Great Dane you are surrendering
Dane Name:*
Age - Years:*
Please enter a number from 0 to 15.
If less than 1 y-o, enter 0 and then the number of months below.
Age - Months:*
Please enter a number from 0 to 12.
Date of Birth (if known):

Day
Month
Year
Colour:*
Select the colour which closest matches.
Gender:*
- Male
- Female
Neutered / Spayed:*
- Yes
- No
Month of last Season:
What Year:*

Enter as YYYY - e.g. 2010
Are its ears cropped:
- No
- Yes
Weight:

Specify lbs or kg.
Height:
Microchip or Tattoo Number:
Reason for Surrender:*

How long have you had the Dane:*
Where did you get the Dane:*
- Breeder
- Friend
- Internet
Is the Dane CKC registered:*
- No
- Yes
Will you sign over registration:*
- No
- Yes
Registration papers are NOT given to Adopters, but retained on file by DiD.
Is this Dane a house pet:*
- No
- Yes
Is this Dane housetrained:*
- No
- Yes
Is this Dane leash-trained:*
- No
- Yes
Has it had Obedience Training:*
- No
- Yes
Do you ever walk it off-leash:*
- No
- Yes
Does it stay with you:*
- No
- Yes
Is it crate trained:*
- No
- Yes

Reaction to being crated:*
Reaction to other dogs:*
Reaction to Cats:*
Has it been exposed to livestock:
- No
- Yes
Reaction to Children:*
Reaction to Strangers:*
Has it ever bitten or shown aggression towards a person:*
- No
- Yes
Detail the circumstances and any injuries sustained:*

What is its General Temperament:*

Examples: Happy-go-lucky, fearful, timid, playful, etc.
What is its Health status/general condition:*
Any Major Health issues or illnesses:*
- No
- Yes
Is the Dane Deaf:*
- No
- Yes
Is the Dane Blind:*
- No
- Yes
Specify these:*
Specify any current medical conditions requiring treatment:*
Has the Dane ever been vaccinated:*
- No
- Yes
Has the Dane ever received a Rabies vaccine:
- No
- Yes
Date of last Rabies Vaccination:

Day
Month
Year
Has the Dane ever received a DA2PPV vaccine:
- No
- Yes
This vaccine is commonly known as Distemper vaccine
Date of last DA2PPV Vaccination:

Day
Month
Year
Please itemize any other vaccines previously given:

Other vaccines may include Bordetella, Lyme, etc.
Has the Dane ever had Heartworm medication:
- No
- Yes
- Don't know
Specify Brand used:*
What Year was the Test done:*
Vet Clinic used for the Dane:*

If no vet, enter N/A
Vet - Street Address:*
Vet - City:*
Vet - Phone:*

How long has the Dane been left alone:*
Where is the Dane kept when no one is home:*
Specify any behavioral issues:*
e.g. chewing, digging, barking, jumping, etc.
The Dane LIKES the following:
e.g. Car rides, walks
The Dane DISLIKES the following:
e.g. nail clipping, baths, etc.
Has it been boarded at a kennel or elsewhere:
- No
- Yes
How did it react:
What food brand is the Dane currently being fed:*
How often is it fed daily:*
How much per meal:
At what time(s) do you feed:
Specify any special feeding instructions:

Are you willing to keep the Dane until a suitable Adopter is found:*
- No
- Yes
Can you keep the Dane at your home until it is altered:*
- No
- Yes
If we can place your Dane, will you make a donation to cover expenses:*
- No
- Yes
Additional Comments:
Do you certify that the answers given are true:*
- No
- Yes
If there are Public Health issues (e.g. human aggression, rabies infection) not disclosed, you could be liable for civil action against you!
Click on the Choose File buttons below and select the photograph filename on your hard drive Photograph size must be less than 1 Mb per picture and picture format must be .jpg.
Upload Picture 1
Accepted file types: jpg, Max. file size: 256 MB.
Upload Picture 2
Accepted file types: jpg, Max. file size: 256 MB.
Upload Picture 3
Accepted file types: jpg, Max. file size: 256 MB.

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