Application for Surrender

Lab Rescue of Greater Richmond
P.O. Box 1574, Midlothian, VA 23113-1574

Phone: (804) 417-7527

info@labrescue-richmond.com
Application for Surrender
Personal Information
First Name: *
Last Name: *
E-mail: *
Cell Number: *
Co-applicant First Name:
Co- applicant /Last Name:
E-mail:
Cell Number:
Address: *
City: *
Zip: *
Lab Information
Dog's Name: *
Is the dog a pure bred Lab? *
A picture of the dog must be attached in order for us to proceed. *
Age: *
Weight: *
Color: *
Sex: *
Spay/Neutered *
How long have you owned the dog? *
Health Issues *
Where did you get dog? *
Where does your dog stay when you are not home? *

Inside, Free reign Inside Crated Baby Gated inside Outside Kennel/Pen outside
Comments:
Where does your dog stay at night? *

Inside, Free reign Inside/ Crated Baby Gated inside Outside Kennel/Pen outside
Comments:
How many hours is the dog home alone on a typical work day?
Help us get to know your Dog. Please check all that appliy *

Likes to fetch Likes to swim Likes car rides Jumps on people Barker Good on leash Pulls on leash Knows Sit Knows Down Knows Come Knows Stay Prey Drive Social with People Nervous in the car High Energy Low energy Food Motivated
Comments on any of the above
Is the dog house trained? *

Yes No
Is your yard fenced

Yes No
If yes, will the dog jump over the fence.

Yes No
Comments on height of fence and style
Is the dog current on vaccines *

Rabies Distemper/Parvo/lepto Bordetella Not current on vaccines
Is the dog currently on Heartworm preventative? *

Yes No
When was preventative last given?
Date of last Heartworm test:
Flea preventative? *

Yes No
Check all that apply *

Dog Friendly Friendly with small dogs Cat Friendly Dog aggressive
Is the dog good with children? *

Yes No Unknown
If Yes, what age childen are they comfortable with
Has the dog bitten a child or adult? *

Yes No
If Yes, Please Explain:
Is the dog good on leash?
Has your dog ever shown any aggression towards other dogs? *

Yes No
Any destructive behaviors we need to be aware of? *
Does your dog display any resource guarding with the following.

Food Toys Crate Bed Humans Other Dogs
Comments
Reason for giving up the dog? *
Does the dog need to be removed immediately or are you able to foster the dog while we find a forever home? *

Remove immediately Remove within a few weeks Can stay until forever home is found
If you have additional information to add to this form, please enter it here:
Is the dog Microchipped?
If Microchipped, where is the chip registered and what is the Microchip Number?
Current Veterinarian
If your dog is not up to date on Vaccines and/or Heartworm Test, are you able to get the dog up to date before surrendering?

Yes, I can get my dog up to date prior to surrendering. No, I am unable to financial afford veterinary care for my dog.
* You will need to give your vet permission to speak with a LRGR volunteer.
I have spoken to my vet and have given them permission to speak with Lab Rescue. *

Yes No
Vet Name: *
Vet Number: *
Vet Address: *
By submitting this electronic form, I acknowledge that all the information on this form is true and correct. I understand that any misrepresentation of fact may result in legal action by Lab Rescue. *

I Agree
Should be Empty:

Lab Rescue of Greater Richmond

Application for Surrender