Owner Surrender Form

Before beginning this form, please have the following information ready:

The name, address, and phone number of your current veterinarian (if you have one) and the date of your dog's latest vaccines.

About You

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Please explain the reason for surrendering your dog. *

About your Dog

Your dog's name: *

Photo of your dog (if available).

Gender of your Dog. *

Female

Male

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

Yes

No

Age of your dog. *

Date of your dog's birth (if known).

Is your dog microchipped? *

Yes

No

I 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? * 🛈

Yes

No

Does your dog have fleas? *

Yes

No

Does your dog have allergies? *

Yes

No

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? (If not, please authorize your vet to share information with us) . *

Yes

No

Other (please explain) Other (please explain)

Where is your dog is kept? List all that apply: house, outside, kennel, tie out, fenced yard, other *

Is your dog... (Check all that apply) *

housetrained

crate trained

obedience trained

none of the above

Commands your dog knows: *

Where is your dog kept when alone? *

Does your dog do any of the following? (Check all that apply) *

Chew

Dig

Jump the fence

none of the above

How is your dog with strangers? *

Has your dog been exposed to children? *

Yes

No

How is your dog with children? *

How is your dog with other dogs? *

Has your dog ever been exposed to cats? *

Yes

No

How is your dog with cats? *

Has your dog ever been exposed to livestock? *

Yes

No

How is your dog with livestock? *

What is the overall energy level of your dog? *

Does your dog bark excessively? *

Yes

No

Other (please explain) Other (please explain)

Is your dog possessive of any of the following? (Please check all that apply.) *

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

Has your dog ever bitten, or attempted to bite any of the following? (Please check all that apply.) *

An adult

A child

Another animal

none of the above

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

Time Frame

Date by which your dog must be rehomed. *

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

Yes

No

Maybe, please explain: Maybe, please explain:

Additional Information

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