AKITA'S full name ______________________________ Callname ___________
Sex: Female Male Spay/Neuter: Yes No Date:__________________
Weight:_______ Age: ______ Age when obtained:_________________
Colors:_________________________________________________
Breeder:________________________________________________
Have you contacted breeder: Yes No Response:______________________
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AKC Registered: Yes No AKC # ___________________ Birthdate ______________
Vet:___________________________________ Phone: __________________________
May we contact your Vet to verify the health and records of Akita? Yes No
Medical Info: Rabies Shots: Yes No Rabies # _________________
Shots: DHLPP CORONA LYME HEARTWORM CHECK: YES NO
Heartworm Medication: Yes No Type:____________________ Monthly: Yes No
Wormed: Yes No For:_____________ Where: _____________ Date: __________
Teeth cleaned: Yes No Date: ________ Extractions: Yes No
Health Problems: Skin Stomach Feet Nails Ears Coat Eyes Nose Displasia
Heartworm (if skin, type of problem)________________________
Treatment for any of above: Yes No Medication: Yes No
Other:______________________Treatment_____________________________________
Surgery For:______________________________________________________________
Is Akita on medication now: Yes No Type:__________________________________
If you did not get Akita from a breeder, where did you get Akita?
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May Akita stay with you while we advertise to find it a home: Yes No
May prospective owners come to your home to see Akita: Yes No
May a foster-home care for AKITA while we find it a home: Yes No
Will you promise not to euthanize the AKITA: Yes No
Who referred you to us:______________________________________________
Will you let us handle the process of placing the Akita? Yes No
Reason for releasing Akita:__________________________________________
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Present Owner's Names:_______________________________________________
Address:_____________________________________________________________
City/State/Zip_______________________________________________________
Home Phone___________________ Work Phone______________________
Please read before you sign and date:
AKITA ADOPTION & RESCUE OF MIDAMERICA (AAROM) is a not-for-profit agency, all proceeds for the Akitas pay for Spay/Neuter, Shots, Feed, Boardig, Advertising and toll calls and gasoline to and from house checks. Any fees charged for the adoption of an Akita, will be used for your specific Akita or for the next Akita that may need more than the above mentioned care. Some Akitas we rescue need much medical attention, or have large board bills. Our fee to adoptive owners ranges from $75.00 to $225.00. All financial records of AAROM are open for inspection. Because we are a not-for profit agency, any time in the future that you are able to contribute a donation for the care of rescued Akitas, it will be greatly appreciated. There is, of course, no obligation.
A representative will visit you to evaluate and take pictures of your Akita to better serve the needs of the Akita in finding the right home.
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Directions to your home:__________________________________________________
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We, of AKITA ADOPTION & RESCUE OF MIDAMERICA promise to do our very best to find the best home for your Akita. We will keep you informed of the potential adopters and give you every opportunity to screen and evaluate them so that you will be comfortable with the individual or family we find for them.
We promise to follow up with the Akita and the adopter, individual or family that the Akita is placed with and if you desire, we will keep you informed on the care, future adjustment and settling in process.
We never place an Akita that we don't feel absolutely good about.
______________________________________Date:______________________
AAROM Representative