Dog Rescue Questionnaire Note: This form can only be filled in by an IMPS Volunteer. If you are not an IMPS Volunteer and you have picked up a dog, please call the IMPS Hotline at 1-877-Minpin1, or contact an IMPS Regional Coordinator nearest to you. Name of Dog: IMPS Tag Number: If you don't have an IMPS Tag, please contact your Regional Coordinator for details. We will not list any dog on our website without an IMPS Tag Number. Microchip Brand & Number: (if available) Age:     Sex (M/F): Male    Female    Don't Know    Spayed/Neutered: Yes    No    Don't Know        If not Spayed/Neutered, Have any plans been made: Color: Height (inches):     Weight (pounds): Docked Tail: Yes    No    Don't Know    Cropped Ears: Yes    No    Don't Know    Shots Up to Date: Yes    No    Don't Know        If not, What shots have been given: Heartworm Testing: All dogs must be on Heartworm Preventative prior to placement. Did the home or shelter provide documentation that heartworm preventative was given regularly?     Yes    No    If No,    Has the dog been heartworm tested recently?    No - please provide the date the dog will undergo testing:    Yes - what was the result? Negative    Positive            If heartworm positive, Is the dog currently under treatment: Yes    No    Reason the Dog is in Rescue: (Please select one) Owner surrender direct to IMPS Reason for surrender Please provide name & address of previous owner Rescue from a shelter Reason the dog was in the shelter (if known) Please provide name & address of the shelter Other (Please provide details) Tell us more about the dog: Where is the dog currently located (please include City/State): Health/Temperament Problems:   House-broken: Yes    No    Don't Know   Crate-trained: Yes    No    Don't Know   OK with strangers: Yes    No    Don't Know   OK with young children: Yes    No    Don't Know   OK with other dogs: Yes    No    Don't Know   OK with cats: Yes    No    Don't Know   Barks excessively: Yes    No    Don't Know   Digs: Yes    No    Don't Know Any other Comments, or suggested Website bio/description for the dog: Additional Notes to be listed on the Website: (Optional) (This shipping and location info WILL be listed on the website bio. If you prefer not to have this online, please leave the boxes blank!)   Can this dog be shipped?     Location of dog? (City)   CONTACT DETAILS: (NOTE: Please complete this section fully. Only the Volunteer's first name and email address will be listed online Phone numbers are never listed on the website). IMPS Volunteers Name: Email Address: Location (City/State): Contact Phone Number (include area code): When should this dog be listed on the IMPS Webpage: Now Adoption Pending.. Please give us some details (current status, potential home details, dates, etc....) Later... If later, please state a reason and possible date for listing Already adopted by: (Please include name and address of Adoptive Home) NOTE: If you have a pic of the dog, email it to Mag at imps@mgbeng.com for inclusion on the IMPS web page (preferably in jpg format). If you don't have an IMPS Tag, please contact your Regional Coordinator for details. We will not list any dog on our website without an IMPS Tag Number. IMPS thanks you for your rescue efforts. Your form will be submitted to Mag at imps@mgbeng.com. If you have any other queries, feel free to contact your IMPS Regional Coordinator. Return to IMPS main page