Dog/Puppy Surrender Form

Dog/Puppy Surrender Form

Answering these questions will assist me in placing your dog in another home so please answer truthfully.
Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOG & HOUSEHOLD INFORMATION
When do you need to surrender the dog?*
Dogs Name*
Sex*

MaleFemale
Age*
Is the dog*

PurebreedMix
Tail*

DockedNatural
How long have you had the dog?*
Where did you get the dog?*
Why are you surrendering the dog?

Including yourself, how many people of the following ages live in your home?*

	FEMALE	MALE
00 - 03
04 - 09
10 - 17
18 - 29
30 - 59
60 +

What other animals did the dog live with?*

no other animalsdogscatsOther
BEHAVIOR

Your dogs usual behavior

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

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

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

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

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

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

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

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

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

friendlyafraidbarksshows teeth/growlswill bite
Is the dog housetrained?*

yesnopartially
How does the dog let you know they need to go out?*
Where does the dog 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 dog 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 dog usually show any of the following behaviors?*

destroy household itemsurinate/defecatebarkcrynone of theseOther
When the dog plays, do they typically...*

jumpsgrowlsbarksbites lightlybites hardnone of theseOther
What toys does the dog like?*

ballsfrisbeeplushsqueakytug toynoneOther
What games does the dog like?*

fetchtugchasewrestlingnoneOther
Is the dog scared of anything*

yesno
If yes, please explain
Please tell us the dogs bad habits*
Is the dog allowed on furniture?*

yesno
Where does the dog usually sleep at overnight?*

crateflooryour bedcouchkids beddog bedoutsideOther
What commands does the dog know?*

no commands knownsitdownstaycomeleave itplaceheelOther
Describe the dogs leash skills*
Describe the dogs reaction if a person or other dog gets near or attempts to take food he is eating.*
Describe the dogs reaction if a person or other dog attempts to take a toy they are playing with.*
Describe the dogs reaction if a person or other dog attempts to take a bone or other treat they have*
Describe the dogs reaction if touched when sleeping.*
Does the dog have problems riding in car?*

yesnodon't know
If yes, please explain
Has the dog 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 dog ever attacked or bit a person?*

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

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

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

yesno
If yes, please explain
MEDICAL
Please list all veterinarians that have seen the dog, including address and number.*
Does the dog see a veterinarian at least once a year?*

yesno
Is the dog spayed/neutered?*

yesno
What vaccinations has the dog recieved?*

rabiesdhhpbordatellanone
Are vaccinations current?*

yesno
Has the dog been tested for heartworm?*

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

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

yesno

Check if the dog has ever shown any of the following behaviors when handled by a vet or groomer.*

	never done	shows teeth/growls	snap	bite	none of these
examine
restrain
administer shots
bathe
clean ears
trim nails
take blood

Does the dog have to be muzzled at the veterinarians?*

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

yesno
If yes, please describe
Is the dog currently taking any medication?*

yesno
If yes, please list medications
FEEDING
What type of food does the dog eat?*

canneddrysofttable scrapsrawhome cooked
How many times a day is dog fed?*

1 time2 times3 timesfree feeds
How much is fed per feeding?*

1 cup1 1/2 cup2 cups2 1/2 cupsnot sure, just fill the bowl upOther
Does the dog get treats?*

yesno
If yes, what treats does the dog like?
OTHER
Please feel free to tell us any other information about the dog you feel is important.
Please upload a full body picture of the dog*

Cancelof
Please upload a up close head shot of the dog*

Cancelof
Please upload any records you have for the dog

Cancelof
Should be Empty:

Dog/Puppy Surrender Form

DOG & HOUSEHOLD INFORMATION

BEHAVIOR

AGGRESSIVE BEHAVIOR

MEDICAL

FEEDING

OTHER