Owner Turn-In Form « Bichon Frise Club of America Charitable Trust

Where is the Bichon?
Name*

First

Last
Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Bichon's Name or Shelter ID*
Gender*
- Male
- Female
Spayed / Neutered?
- Yes
- No
Age*
Has the Bichon ever bitten anyone? If Yes, under what circumstances?*

(Dates occurred, number of times, adult, child, family member or stranger, dog provoked, dog in a crate or backed up in a corner, dog ill, dog eating, dog fearful, dog aggressive, etc.)
Bichon's Health or Health Care Requirements*

Describe in detail whether the dog is known to be or appears to be healthy, OR if there are any known or apparent health problems (heartworm, kennel cough, parvovirus, blindness, cataracts, deafness, paralysis, ringworm, demodectic mange, ear mites, tape worms, hypothyroidism, Cushing’s or Addison’s disease, autoimmune diseases, cancers, heart diseases, pancreatitus, gastritis, seizures/epilepsy, patellar luxation, hip dysplasia, ruptured discs, bladder stones, severe gum disease, severe inhalant or flea allergies, etc.) Also, describe in detail any known or apparent short term or long term health care requirements/costs (medications required, frequency, treatments, surgeries required and costs if known, special foods and diets, etc.)
Has the Bichon been tested for heartworms?
- Yes
- No
If tested, what were the results?
Date of Test
Is Proof Available?
Bichon's Physical Characteristics/Appearance

(Missing an eye, missing a limb, extremely dirty and/or matted and needs shaving/bath, already shaved and bathed, missing hair due to trauma or disease, rashes; Or in fairly good to great condition: not matted, basically clean and groomed, well cared for, etc.)
Is the Bichon Housebroken?

(completely housebroken, rarely accidents, frequent accidents, circumstances surrounding when accidents occur)
Has the Bichon been around children?*

(number of children, ages, sex, lived with or exposed, frequency, good or bad experiences with children, etc. )
Has the Bichon been around other animals?

(types of animals, number, sex, spayed/neutered, lived with or exposed, frequency, good or bad experiences with which animals, etc.)
What is the Bichon's general temperament?*

(aggressive, shy, fearful, quiet, timid, barks excessively, good or bad with strangers, prefers male or female humans, fearful or aggressive with children, fearful or aggressive with other animals, etc.)
Reason this Bichon is being placed into rescue*
Urgency of Rescue

How long can the dog be maintained until a rescue volunteer needs to take possession?
Information About You
Name

First

Last
Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Organization
Email
Day Phone
Evening Phone
Are you the Owner/Guardian of the Bichon?*
If No, please give the Owner/Guardian’s Information:
Name

First

Last
Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Email
Day Phone
Evening Phone
How long has the current owner had this Bichon?
How and where was this Bichon obtained?*

(purchased, gift, adopted; From whom: Breeder’s Name, Store’s name, Shelter’s Name, address, phone number, etc.)
Is this Bichon microchipped or tattooed?
Is there a crate in good condition that can be provided along with the Bichon?
What kind or brand of food was the Bichon fed?
Does the Bichon have current Rabies vaccination?

Also state Date, if known (MM/DD/YY)
Current DHPP or combo vaccination?

Date, if known (MM/DD/YY)
Can you provide proof of these Vaccinations?
Is the Bichon currently on Heartworm prevention?

Brand given/frequency, Date last given (MM/DD/YY)
I hereby give permission for the Veterinarian listed below to release to the Bichon Frise Club of America Charitable Trust's designee all medical records for the dog named on this form. (Initial in this box to grant permission:)
I certify that the Veterinarian and Clinic listed below are the current medical providers for this dog, and that the records they provide will be the most current and complete records available. (Initial in this box to certify:)
Veterinarian Information
Name*
Clinic / Hospital Name
Email
Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Any additional comments?
Before you click the submit button, please read this:

From the moment we receive your information, we take action. Arrangements are made for transport, a foster home, and more. We make every effort to work with you to re-home the Bichon.

Please remember, however, that we are all volunteers, with jobs, families and commitments. We will do our best to respect your time, and only ask the same in return.
Please have your vet fax all medical records to 866-473-0722

It is important that we have the health information on the Bichon to better assist in placing. Please email a photo of the dog (with name) to bfcact@verizon.net

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