Intake Questionnaire - Danes in Distress

The Surrender Intake form is separated into 7 stages. Each stage will be verified for required answers before proceeding to the next section.

Your dog will be placed much sooner if you can supply photograph(s). Total size must be less than 1 Mb per picture and the picture format must be jpeg (.jpg). Please, no humans in the photographs!

If you do not know the answer to a question, just answer N/A. If multiple choice questions don't show the answer you want, you can enter further explanation in the 'Additional Comments' at the end of the form.
Your Full Name:*
First Last
Do you have an email address:*
- Yes
- No
Email:*
Enter Email Confirm Email
Primary Phone:*

Enter only numbers - e.g. 555 555 5555.
Cell Phone:

Enter only numbers - e.g. 555 555 5555.
Business Phone:

Enter only numbers - e.g. 555 555 5555.
Street Address:*
City:*
Province:*
Select your Province
Postal Code:*
Closest major City:

Answer this if you live in a rural community.
How did you hear about Danes in Distress:

2 - About the Great Dane you are surrendering
Dane Name:*
Age - Years:*
Please enter a number from 0 to 15.
If less than 1 y-o, enter 0 and then the number of months below.
Age - Months:*
Please enter a number from 0 to 12.
Date of Birth (if known):

Day
Month
Year
Colour:*
Select the colour which closest matches.
Gender:*
- Male
- Female
Neutered / Spayed:*
- Yes
- No
Month of last Season:
What Year:*

Enter as YYYY - e.g. 2010
Are its ears cropped:
- No
- Yes
Weight:

Specify lbs or kg.
Height:
Microchip or Tattoo Number:
Reason for Surrender:*

Are you willing to keep the Dane until a suitable Adopter is found:*
- No
- Yes
Can you keep the Dane at your home until it is altered:*
- No
- Yes
If we can place your Dane, will you make a donation to cover expenses:*
- No
- Yes
Additional Comments:
Do you certify that the answers given are true:*
- No
- Yes
If there are Public Health issues (e.g. human aggression, rabies infection) not disclosed, you could be liable for civil action against you!
Click on the Choose File buttons below and select the photograph filename on your hard drive Photograph size must be less than 1 Mb per picture and picture format must be .jpg.
Upload Picture 1
Accepted file types: jpg, Max. file size: 256 MB.
Upload Picture 2
Accepted file types: jpg, Max. file size: 256 MB.
Upload Picture 3
Accepted file types: jpg, Max. file size: 256 MB.

2 - About the Great Dane you are surrendering