Animal Surrender Form

Animal Surrender Form
Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOG & HOUSEHOLD INFORMATION
Animals Name & Breed*
Sex*

MaleFemale
Age*
Is the animal?*

PurebredMix
How long have you had the animal?*
Where did you get the animal?*
Why are you surrendering the Animal?
What other animals did the animal live with?*

no other animalsdogscatsOther
BEHAVIOR

Your dogs usual behavior

How does the animal usually behave towards people they know?*

	never a bad encounter	friendly	afraid	show teeth/growl	snaps	bites	other
men
women
children

How does the animal usually behave towards people they DO NOT know?*

	never a bad encounter	friendly	afraid	show teeth/growl	snaps	bites	other
men
women
children

How does the animal usually behave towards animals they know?*

	never a bad encounter	friendly	afraid	show teeth/growl	snaps	bites	other
dogs
cats

How does the animal usually behave towards animals they DO NOT know?*

	never a bad encounter	friendly	afraid	show teeth/growl	snaps	bites	other
dogs
cats

Comments on answers above
How does the animal usually react when an unfamiliar person approaches or enters the yard or house?*

friendlyafraidbarksshows teeth/growlswill bite
Is the animal housetrained?*

yesnopartially
How does the animal let you know they need to go out?*
Where does the animal spend the majority of their time?*

inside the house, runs freeinside the house, cratedoutside the house, runs free in yardoutside the house, kenneloutside the house, tied upOther
How many hours a day is the animal left alone without a human?*

never1-3 hours4-8 hours9-12 hoursover 12 hours
When left alone, is he/she...*

outdoorsfree roam in homeconfined to a roomcratedOther
When left alone, does the animal usually show any of the following behaviors?*

destroy household itemsurinate/defecatebarkcrynone of theseOther
Is the animal scared of anything specific?*

yesno
If yes, please explain
What commands does the animal know?*

no commands knownsitdownstaycomeleave itplaceheelOther
Does the animal have problems riding in car?*

yesnodon't know
If yes, please explain
Has the animal escaped your property 2 or more times in the last 6 months?

yesno
If yes, please explain
AGGRESSIVE BEHAVIOR

(behavior that has ever happened)
Has the animal ever attacked or bit a person?*

yesno
If yes, please explain
Has the animal ever attacked or bit another dog?*

yesno
If yes, please explain
Has the animal ever attacked or bit a cat?*

yesno
If yes, please explain
Has the animal ever attacked or bit farm animals? (chickens, horses, cows, goat, pig, sheep, etc...)*

no
If yes, please explain
MEDICAL
Please list all veterinarians that have seen the animal, including address and number.*
Does the animal see a veterinarian at least once a year?*

yesno
Is the animal spayed/neutered?*

yesno
What vaccinations has the animal recieved?*

rabiesdhhpbordatellanone
Are vaccinations current?*

yesno
Has the animal been tested for heartworm?*

yesno
If yes, what were test results
Is the animal taking heartworm preventative?*

yesno
If yes, when is the next dosage due?
Is the animal microchipped?*

yesno
Does the boxer have to be muzzled at the veterinarians?*

yesno
Does the animal have any past or present health problems?*

yesno
If yes, please describe
OTHER
Please feel free to tell us any other information about the boxer you feel is important.
Please upload a full body picture of the animal

Cancelof
Please upload a up close head shot of the animal

Cancelof
Please upload any records you have for the boxer

Cancelof
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Animal Surrender Form

DOG & HOUSEHOLD INFORMATION

BEHAVIOR

AGGRESSIVE BEHAVIOR

MEDICAL

OTHER