Owner Surrender Form

Owner Surrender Form
Sometimes, unfortunate circumstances dictate the need to find a new home for our pets. We understand that giving up your pet is a difficult decision, but we realize that in making this choice, you are thinking about your dog’s best interests. When you are ready we are here to help.

Please provide as much information as possible. Above all, please be honest; we understand your dog may not be perfect, but the more we know the better we are able to find the perfect new home for your dog.
Date *

Day Month Year
Dog’s Name *
Owner Name *
Owners Adress *

Street Address

City State / Province

Postal / Zip Code
Phone *
Email Adress *
Breed *
Gender *

Male Female
Spayed/Neutered *

Yes No
Dog’s Birthday *

Day Month Year
Age *
Dogs Weight *
Is dog good with other dogs? *

Yes No
Is dog good with cats? *

Yes No
Is dog good with young children? *

Yes No
Is dog good with older children? *

Yes No
Is dog microchipped? *

Yes No
Microchipped number *
Date of last Vet visit: *

Month Day Year
Date
Reason for visit:
Medical/Vaccine records provided? *

Yes No
Name and Phone number of veterinarian/animal clinic:
Date of last Rabies Vaccine

Month Day Year
Date
Date of last Bordetella Vaccine

Month Day Year
Date
Date of last Heartworm test

Month Day Year
Date
Heartworm prevention given? *

Yes No
Product used *
Date next dose due

Month Day Year
Date
Flea protection given *

Yes No
Product used
Date next dose due

Month Day Year
Date
Does your dog have health issue? *

Yes No
If yes Please explain
Is your dog on medication? *

Yes No
If yes please list meds
Please supply some of the dog's current food for transition and any current medications.
Reason for surrender *
Donations $ *
I am surrendering the above mentioned dog to GRSF of my own free will. I acknowledge that my signature and submission of this form relinquishes all claims of ownership of the dog described. Neither my family, any representatives acting on my behalf, nor I may assert present and/or future claims, suites, or otherwise against Golden Rescue South Florida, Inc. with respect to this dog. I understand that the Golden Rescue South Florida, Inc. will not return the dog to me, once left in its care, under any circumstances, unless otherwise approved by the Golden Rescue South Florida, Inc. Board Director.
Owner Signature *

Clear
Date

Month Day Year
Should be Empty: