Portland – Small Pet Intake Small Animal Intake Form POQ – April 2023 "*" indicates required fields Your Name* First Last Phone Number*Email* Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pet's Type* Rabbit Guinea Pig Rat Hamster Chinchilla/Degu Bird Other Pet's Name* Age in Years*0123456789101112131415161718192021222324252627282930+Use if the animal is over 1 years old, otherwise leave as 0Age in Months*0123456789101112Use if the animal is over 3 months old, otherwise leave as 0Age in Weeks*0123456789101112Use if the animal is below 3 months old, otherwise leave as 0Pet's Gender* Male Female Is the pet spayed/neutered?* Yes No How long have you owned this pet?* Where did you acquire this pet?* Has this pet ever bitten?* Yes No Why do you need to rehome this pet?*Are there any places on this pet's body that it does not like to be touched?* Yes No Can you pick up and hold this pet?* Yes No How long can you hold this pet?* Where was this pet mainly kept?* Indoors Outdoors Describe this pet's housing (cage, hutch, etc.):*Is this animal litter box trained?* Yes No What is your pet's current diet? (Check all that apply)* Pellets Alfalfa hay Seed Fresh fruit Fresh veggies When do you feed? (Check all that apply)* AM PM Free feed Does this pet prefer their water from:* Water bottle Floor bowl This animal is compatible with (check all that apply):* Young children (babies/toddlers) Older children/Teens Visitors Same species as pet Cats Dogs Other How would you describe this pet? (Check all that apply)* Playful Affectionate Outgoing Shy Easy-going Lap pet Active Independent What are this pet's favorite toys?*What does this pet like to chew on?*HiddenDoes this pet have any known illnesses or conditions? Yes No Has this pet seen a vet in the last year?* Yes No Is your pet currently taking any prescribed medications?* Yes No Please list all current medications Has your pet been diagnosed with a chronic medical condition that requires ongoing medical care?* Yes No Please describe the Pet's medical condition Is there anything else you would like us to know about this pet?The average daily cost for caring for each animal we receive is $150. We ask for a donation from each family using our services to help us in caring for your pet. Please indicate the amount you can comfortably afford to donate. Every dollar helps!*Please only include numbers. No symbols or letters. ex: I want to donate $150, I would put 150 in the boxIf you require language interpretation services, please select your preferred language below. Arabic Cantonese French German Italian Japanese Korean Mandarin Persian Portuguese Russian Spanish Vietnamese Other Untitled PhoneThis field is for validation purposes and should be left unchanged.
