Owner Surrender Form (test)

First Name *

Last Name *

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City *

State *

ZIP Code

Please explain the reason for surrendering your dog. *

Your dog's name *

Age of your dog *Provide the date of your dog’s birth (if known).

Gender of your dog *FemaleMale

Is your dog altered (spayed/neutered/fixed)? *YesNo

How long have you owned your dog? *

Is your dog microchipped? *YesNoI don’t know

Your dog's color *

Your dog's weight *

Name and address of your veterinarian *

Date your dog last saw a vet. *

What was the reason for this visit? *

Does your dog have hotspots? *YesNo

Does your dog have fleas? *YesNo

Does your dog have allergies? *YesNo

When did your dog last receive the following vaccinations: Rabies, DHLPP, Bordatella? *

When is your dog due for their next vaccinations: Rabies, DHLPP, Bordatela? *

When did your dog last receive a heartworm test? *

What was the result of this heartworm test? *

What kind of heartworm preventative is your dog on? *

Does your dog have a history of any injuries or illnesses? Please give full details. *

Are vet records available? *YesNo

If not, please authorize your vet to share information with us or explain (below) why those records are not available.

Is your dog… *

housetrainedcrate trainedobedience trainednone of the aboveCheck all that apply

Commands your dog knows: *

How is your dog with strangers? *

Where is your dog kept when alone? *

Does your dog do any of the following? *

ChewDigJump the fencenone of the aboveCheck all that apply

Has your dog been exposed to children? *YesNo

Has your dog ever been exposed to cats? *YesNo

Has your dog ever been exposed to livestock? *YesNo

What is the overall energy level of your dog? *

Does your dog bark excessively? *YesNoOther

Please explain

Has your dog ever bitten, or attempted to bite any of the following? *

An adultA childAnother animalnone of the aboveCheck all that apply

Please explain

Does your dog have specific fears or phobias? (such as storms, fireworks, etc) *

Date by which your dog must be rehomed. *

Please describe the personality of your dog, his/her likes dislikes, issues, etc. *

Are you willing to continue to care for your dog while we look for a new home for him or her? *YesNoMaybe

Please explain

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Any other comments or information you would like us to know? *

Owner Surrender Form (test)

Where is your dog is kept? *

Is your dog… *

Does your dog do any of the following? *

Is your dog possessive of any of the following? *

Has your dog ever bitten, or attempted to bite any of the following? *