AGN Surrender Form

AGN Surrender Form

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

MonthDayYear
Date
Exact or Approximate
If birthdate is approximate, please explain.
Is your dog spayed/neutered?
Is the dog a purebred or mixed breed? If mixed, what breeds?
Gender
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?
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.Format: (000) 000-0000.
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?
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?
Does your dog have hot spots/skin problems?
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?
Attempt to run out of open doors from the home?
Jump fences?
Dig?
Attempt to escape from a fence in any way?
If yes, explain how
Like to ride in a car?
Like to swim?
Allow you to take toys from them?
Chase cars?
Urinate when scared?
Come when called?
Growl at strangers?
Is your dog...
Housetrained?
Crate trained?
Afraid of storms?
Afraid of men?
Currently living with children?
If yes, what age of the children?
Good with children?
Good with cats?
Good with other dogs?
Used to being groomed?
Used to being leash walked?
Good on a leash? (doesn't pull)
Obedience trained?
What commands does your dog know?
Has your dog ever bitten a human?
If yes, please explain
Has your dog ever been attacked by another dog?
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.Format: (000) 000-0000.
Secondary phone number
Please enter a valid phone number.Format: (000) 000-0000.
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...