Animal Placement Form

Name_______________________________________________________________

Address__________________________________Telephone_____________________

City, State,Zip_____________________________ Date________________

Pet's Name_______________________________ cat dog rabbit other (circle one)

Breed___________________________________ Color(s)___________________________

Sex _________ spayed/neutered or unaltered Birthdate___________________

Declawed Y N Weight_______________ Housebroken/litterbox trained Y N

Date of last vaccinations:______________________________

Vaccinations given:___________________________________

Rabies tag number:___________________________________

Pet's current veterinarian:_______________________________________________

Diagnosed Health problems, special diets, or medications

___________________________________________________________________________________________________

Please describe pet's temperament (i.e. good with kids, others of its own

kind,

etc):____________________________________________________________________________________________________________________________________________

Reason for giving pet up for

adoption:________________________________________________________________

To the best of my knowledge, this is a true and accurate description and statement of my pets health.

By signing this form, I give consent for MERLIN'S REFUGE to seek a new home

for the pet described above. INDIVIDUALS REFERRED TO ME BY MERLIN'S REFUGE

WILL NOT BE CHARGED ANY FEES TO VIEW THE PET DESCRIBED ABOVE. INDIVIDUALS REFERRED TO ME BY MERLIN'S REFUGE WILL NOT BE ASKED FOR ANY FORM OF COMPENSATION FOR ADOPTION OF THE PET DESCRIBED ABOVE.

Signature of pet owner_______________________________________________________

Please include photo of pet and proof of ownership (copy of rabies certificate) with consent form.