AGN Surrender Form

AGN Surrender Form

www.adoptagoldennashville.org
Dog's Name
Dog's Birth Date

MonthDayYear
Date
Exact or Approximate

ExactApproximate
If birthdate is approximate, please explain.
Is your dog spayed/neutered?

YesNo
Is the dog a purebred or mixed breed? If mixed, what breeds?*
Gender

MaleFemale
Age
Weight
How old was your dog when you acquired it?
Where did you acquire your dog from?
Name, address and phone number of breeder (if applicable)
Is your dog microchipped?

YesNo
If yes, company and microchip #
Information on most recent vaccinations (please email copies of vet records if available to info@adoptagoldennashville.org)
Name of Primary Veterinarian
Address of Primary Veterinarian

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number of Primary Veterinarian
Please enter a valid phone number.
Vaccination/Treatment (Please enter date given and name of vet)
Annual Shots (e.g. DHLPP)
Rabies Vaccination
Bordatella (Kennel cough)
Last Heart-worm check
Is your dog on monthly heartworm preventative?

YesNo
What kind of heartworm preventative is your dog on?
Date last heartworm preventative given.

MonthDayYear
Date
Last flea/tick treatment (e.g. Frontline)
Does you dog have chronic ear infections?

YesNo
Does your dog have hot spots/skin problems?

YesNo
Does your dog have other health conditions? Please explain
Has your dog ever had a sudden injury or surgery other than being spayed/neutered? If so, please explain and list year
Vet name, address and phone number where injury was treated or surgery performed
What brand of dog food do you feed your dog?
How much do you feed your dog?
When, and how many times do you feed your dog per day?
Where does your dog sleep?
Where does your dog live/stay during the day or when humans are not home?
Does your dog...
Have separation anxiety?

YesNo
Attempt to run out of open doors from the home?

YesNo
Jump fences?

YesNo
Dig?

YesNo
Attempt to escape from a fence in any way?

YesNo
If yes, explain how
Like to ride in a car?

YesNo
Like to swim?

YesNo
Allow you to take toys from them?

YesNo
Chase cars?

YesNo
Urinate when scared?

YesNo
Come when called?

YesNo
Growl at strangers?

YesNo
Is your dog...
Housetrained?

YesNo
Crate trained?

YesNo
Afraid of storms?

YesNo
Afraid of men?

YesNo
Currently living with children?

YesNo
If yes, what age of the children?
Good with children?

YesNo
Good with cats?

YesNo
Good with other dogs?

YesNo
Used to being groomed?

YesNo
Used to being walked?

YesNo
Good on a leash? (doesn't pull)

YesNo
Obedience trained?

YesNo
What commands does your dog know?
Has your dog ever bitten a human?

YesNo
If yes, please explain
Has your dog ever been attacked by another dog?

YesNo
If yes, please explain
What are your dog's best qualities?
What are your dog's worse qualities?
What does your dog enjoy? e.g. favorite toy, activity etc
What does your dog dislike? e.g. fears
Where do you feel would be an ideal home for your dog?
Is there any other information which you feel will be helpful for your dogs new home?
Why are you surrendering the dog?*
ATTESTATION BY THE RELINQUISHING OWNER(S): I / We certify that I / we own the above dog and that this dog has not shown any signs of aggression, or bitten anyone in the past ten days without disclosure to AGN and that the statements above are true and accurate. I / We agree to indemnify and hold harmless Adopt a Golden Nashville (AGN) by, from and against all claims, suits, damages, liabilities and costs related to or in any manner connected with this dog. I / We further acknowledge understanding that the dog becomes the property of AGN, and that they may place the dog, spay/neuter, or euthanize if in the best interest of the dog.
Date in which this form is being completed?

MonthDayYear
Date
Owner's name*

First NameLast Name
Co-owner's name

First NameLast Name
Email address*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Secondary phone number
Please enter a valid phone number.
Please verify that you are human*
Should be Empty:

AGN Surrender Form

Information on most recent vaccinations (please email copies of vet records if available to info@adoptagoldennashville.org)

Vaccination/Treatment (Please enter date given and name of vet)

Does your dog...

Is your dog...