Name___________________________________________________________________________
Address_________________________________________________________________________
Phone No._______________________________________________________________________
Date of Birth_______________ Are you: (a)married (b) single or widowed
If currently married, name of spouse:_________________________________________________
1. Are you interested in adopting a : (a) cat (b) dog
2. If you chose (b) dog, are you physically able to provide it with proper exercise? (a) yes (b) no
(c) a cat would better fit my lifestyle.
3. Your residence is (a) owned (b) rented (c) condo
4. If you rent, does your lease allow pets? (a) yes (b) no (c) n/a
Landlord's name_____________________ Phone #______________________
5. If you own a condo, does the condo, association allow pets? (a) yes (b) no (c) n/a
Name of an officer in the condo association___________________________________
Phone #______________________________
6. Do you have a fenced yard? (a) yes (b) no
How high is your fence?_________________________
7. Do you work? (a) retired (b) full-time (c) part-time (d) volunteer
If so, ho many hours do you work or volunteer?_______________________
8. Would you be the primary care giver to your pet? If not, please list the name and phone of
the person assisting you:_______________________________________________________
9. Do you have any allergies to the pets that you know of? If so please specify:
_______________________________________________________________________________
10. Where will the pet be kept during the day?________________________________________
During the night?________________________________________________________________
11. Do you have any other pets at this time? Please specify: ____________________________
12. Have you ever had a pet before? (a) cat (b) dog (c) other
13. What happened to your pet?
14. Past veterinarian's name and city and state where located:
_______________________________________________________________________________
15. Name and address of veterinarian that you would prefer to use:
_______________________________________________________________________________
16. Although Pets for Seniors will assist you with some of your veterinarian expenses, we do not cover most of the costs. Are you able to financially care for your pets health needs? (a.) yes (b) no (c) I don't know, please council me on average costs.
17. Sometimes it takes a new pet several weeks to adjust to a new home. It is comon for cats to hide and for both cats and dogs not to eat for a day or two. Even housebroken dogs may have an accident in the first few days. Are you willing to give your pet at least four weeks to adjust? (a) yes (b.) no
