Surrender Form

Please be as truthful as possible regarding your dogs behavior. Check your email for updates!

    Owner's name:


    City: State: Zip:


    Primary phone:

    Dog's Information:


    Dog's date of birth (Please estimate if unknown):

    Sex of dog:MaleFemale


    Primary Breed:

    Secondary Breed:


    Weight (in lbs):

    Describe your dog's temperament:

    How long have you had your dog?

    Where did you get your dog from?

    If you got this dog from a breeder, shelter or rescue group, which one?

    Why do you need to rehome your dog?

    Have you contacted other rescue groups to rehome this dog? If yes, which ones and what was their response?

    Can you keep this dog until we find a new home?

    If not, when would you like the dog to be placed? DO NOT PUT TODAY!

    How much time does your dog spend alone during the day?

    Where is your dog kept when he/she is alone?

    Is the dog house trained?YesNoPartially

    If partially, explain:

    Is the dog crate trained?YesNo

    What brand of food does the dog eat?

    Where does the dog sleep at night?

    Does the dog have any health problems? If yes, please explain:

    Date of last vet visit?

    Name, city and state of vet clinic?

    What exact name are this dog's records stored under at the vet clinc?

    Do you have a copy of the dog's records to give us?YesNo

    When was the dog's last heartworm test done?

    Household Information:

    Number of adults living with your dog?

    Number of children living with your dog?

    Ages of children?

    Dog's reaction to children:

    Provide any details relevant to your dog's behavior around children:

    List other kinds of pets your dog has lived with:

    How does your dog behave around other pets?

    When visitors come to the door, how does your dog react?

    How long does it take to calm down?

    Dog displays the following behaviors (please check all that apply):
    Jumps on peopleJumps fencesUrinates/defecates in houseDigsDestructive chewingChases cars/bikeschases/kills small animalsRuns awaySteals foodGuards/protective of food/toysBarks excessivelySeparation anxietyThunderstorm anxietyOther:

    Do you have a fenced yard?YesNo

    If yes, does it contain the dog? YesNo

    Is your dog allowed off leash?YesNo

    If yes, does the dog come when called?YesNo

    Describe the dog's reaction to meeting other dogs on/off leash:

    How do you exercise your dog? .

    Does your dog play with toys? If yes, what kinds?

    Which of the following does your dog enjoy? (Please check all that apply)
    riding in the cargoing on walksbeing pettedbeing brushedplaying fetchhuntingswimmingjoggingobedience trainingplaying with other dogsplaying with childrenplaying tugplaying frisbeedoing agilityother:
    Are there any parts of the body that your dog doesn't like to have touched, and how does he/she let you know?

    Describe any situation where your dog has snapped, nipped or bitten anyone?

    How do you discipline your dog?

    What concerns do you have about placing your dog in a new home?

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    This form is complete, and I am ready to submit it.

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