Dog Surrender Form

Dog Surrender Form

PLEASE NOTE: Filling out this form does not mean we will accept all animals as surrenders, but this is the first step in the surrender process. Please review all information on the DRHS Rehoming web page before filling out this form and take all necessary steps provided.
**Requirements to surrender:
- You must be the actual owner of the animal.
- You must be approved to surrender and have a surrender appointment before bringing the animal to the shelter.
- The costs associated with helping to place animals are substantial (shelter, food, medical care, etc.). There are fees for surrendering an animal to the Dubuque Regional Humane Society that must be paid for us to be able to take the animal.
Date*

MonthDayYear
Date
I agree and acknowledge that I have fully reviewed and read through the DRHS's rehoming web page before completing this form.*

Yes
I understand and acknowledge that there will be surrender fee associated with rehoming my animal that must be paid.*

Yes

Owner Information
Owner Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Your Date of Birth*

MonthDayYear
Date

Dog Information
Dog Name*
Species*
Breed/Type*
If purebred, do you have AKC papers?
Age*
Approximate Weight*
Sex*
Altered (spayed or neutered?)*
Has your dog ever bitten a person or another animal?*
What vaccines, if any, is your dog current on?*

RabiesDistemperParvoBordetellaFlea/TickHeartworm MedicationNone
Veterinarian*
Date of Last Vet Visit

MonthDayYear
Is your dog microchipped?*
Reason for Rehoming:*
How long have you had your dog?*
Where did you get your dog?*
Is your dog good with other dogs? Please describe history, including interactions with female dogs vs male dogs, etc.*
Is your dog good with cats? Please describe history*
Is your dog good with children? Please describe history, including ages of children*
Is your dog good with strangers? Please describe history, including if they react differently to men vs. women*
Does your dog show any type of aggression, including but not limited to toy aggression, food aggression, barrier reactivity, stranger reactivity, etc.*
Is your dog house broken (potty trained)?*
Is your dog crate trained?*
What is your dog's current diet?*
Does your dog have any health concerns (or on any current medications)?*
Does your dog have any behavioral concerns?*
Your dog lives:*
If you are located outside of the Dubuque, Iowa area, what other shelters or rescues have you contacted?*
If the reason for surrendering is medical related, what steps have you taken to address this, if any?*
If the reason for surrendering is behavior/temperament related, what steps have you taken to address this, if any?*
What do you think is the ideal home for your dog?*
What else should we know about your dog? Likes, dislikes, favorite things, personality notes, etc.*
Attach Photo(s) of Animal:

Please include any attachments (e.g., logo, mission statement, annual report, etc.) that would help us better understand your company's needs.
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Attach Relevant Medical Records

Please include any attachments (e.g., logo, mission statement, annual report, etc.) that would help us better understand your company's needs.
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I acknowledge that I have reviewed the DRHS rehoming website and taken the necessary steps before considering rehoming through the shelter. I agree that I have filled out this form truthfully and to the best of my knowledge, and have an understanding that filling this form out does not automatically mean the DRHS will accept this animal. I lastly acknowledge that there there will be a surrender fee associated to rehoming this animal that will be due before the animal is accepted.*

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