Owner Surrender Request Form
OWNER'S NAME:
First Name
Last Name
Address
Street Address
Mailing Address (if different than street address)
City
State
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Do you accept text messages?
Yes
No
Email
If your email bounces, we won't contact you. Please double check you've typed it correctly!
Dog's name
Primary Breed
Sex of Dog
Female unaltered
Female spayed
Male unaltered
Male neutered
Age / DOB of Dog
Best estimate if unknown
Approximate Weight of Dog
Best estimate
Reason for Surrender
Please be as detailed as possible
Any Medical Issues? If so please describe below.
Please be as detailed as possible
Is your dog up-to-date on the following vaccinations? (Check all that apply)
Rabies
Distemper/Parvo
Bordatella
Other (Flu, Lepto, etc.)
Is your dog currently on monthly heartworm preventative?
Yes
No
Date of last heartworm preventative dosage?
Is your dog good with children?
Is your dog good with other dogs? Cats?
Is your dog crate trained?
Yes
No
Is the dog dominant? Aggressive? Has he/she ever bitten anyone hard enough to break the skin? Please share any behavior concerns here.
Please list any "bad" dog behaviors (digging, escape artist, chewing, etc.)
When and where did you get this dog?
Is the dog microchipped?
Yes
No
Unknown
Name & Phone Number of last known vet and date seen?
Are you able to obtain current vet records?
Yes
No
Please attach current, clear photo of dog
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