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Contact Information
* First Name : 
* Last Name : 
* Address 1 : 
   Address 2 : 
* City : 
* State : 
* Zip : 
* Phone : 
Email Address : 
 
 
 
Dog's Name
   
 
 
 
Breed
   
 
 
 
Dogs DOB (approx).
 
 
 
Dog's Weight
   
 
 
 
 
 
Male
 
Female
 
 
 
 
 
Neutered
 
Spayed
 
Intact
 
Intact but planning to fix
 
 
 
Where did you get your dog?
 
Professional breeder
 
Shelter/Rescue
 
Stray
 
Other
 
 
 
 
Why did you choose this particular breed?
 
Family dog
 
Gender
 
Companion
 
Cute
 
Protection
 
Hunting
 
Athletic
 
Hypoallergenic
 
Other
 

 
 
 
How old was your dog when you acquired him/her?
   
 
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