Surrender Form

    Email:

    Verify Email:

    Name (First, Last):

    Street:

    City:

    County:

    State:

    Zip Code:

    Home Phone:

    Alternate Phone:

    Pet Information

    Dog’s Name:

    Age:

    How long have you had this dog:

    Color:

    Gender:

    Spayed / Neutered?

    Height at Shoulder:

    Weight:

    Cropped ears?

    Microchipped?

    Purebred?

    If no, mixed with what?

    Why do you need to find a new home for the dog?

    When do you need to find a home for the dog?

    Where does the dog stay during the day?

    Where does the dog stay at night?

    Housebroken?

    Crate Trained?

    Still Crated?

    Donate Crate?

    Good with big dogs?

    Good with small dogs?

    Good with cats?

    Good with children?

    If no to any, explain:

    Age of children living with the dog?

    Obedience trained?

    Destructive?

    Behavioral Problems:

    Dog behavior when meeting new people:

    Is or has the dog lived as an only dog?

    If no, age, size, gender of other dogs:

    Name of Veterinarian:

    Veterinarian Phone:

    Other Veterinarian Contact:

    May we contact the vet?

    Current on shots?

    Date of last shots:

    Current on Heartworm preventative?

    If no, how long off preventative:

    Any medical problems:

    Brand of dog food:

    Can you email pictures?

    Can rescue meet the dog?

    How far will you transport the dog to rescue?

    Know Breeder?

    Contract with breeder to return?

    Breeder Contact Info:

    Papers?

    Kind of Papers?

    If dog has bitten or attempted to bite a person, please give details:

    If dog has bitten or attempted to bite an animal, please give details:

    Can you provide a cash donation to offset rescue expenses?

    Additional information and comments:

    Please check the box below:

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