DRNC Surrender Form

Surrender Form

ALL QUESTIONS MUST BE ANSWERED OR FORM WILL BE RETURNED FOR COMPLETION. TYPE IN N/A IF A QUESTION DOES NOT APPLY.
Date of Submisson *

Month Day Year
Dog's Information
Dog's Name *
The dog is a *
If a Dachshund mix, name of breed mixed with:

Chihuahua Basset Hound Beagle Fox Terrier Pit Bull Terrier (unknown) Yorkshire Terrier
Where did you obtain the dog? *
Why are you surrendering the dog? *
Age *
Weight *
Sex *
Color *
Coat *
Owner's Information
Full Name *

First Name Last Name
E-mail *
Cell Phone Number *

Area Code Phone Number
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Veterinary and Medical Information
Veterinarian *
Phone Number *

Area Code Phone Number
Is the dog spayed/neutered? *

yes no
If not, will you have this done?

yes no
Spay/Neuter Fee:

If the dog is NOT spayed or neutered at the time of surrender, a $100 fee may be charged unless the dog is of advanced age or has a medical issue which precludes the procedure. The fee MUST be paid at the time of surrender, unless other arrangements have been made in advance.
Are the dog's vaccinations current? *
If not current, will you update vaccinations?
Microchip Company

Please provide the dates of the last vaccinations: *

	Date
Rabies
DHLPP
General checkup
Heartworm test

Please upload a copy of the dog's shot records. *
Is the dog on Heartworm prevention? *

yes no
Is the dog micro-chipped? *
Microchip ID #
Does the dog have any allergies (flea allerfies, food allergies, etc.)? *
Medical history (describe illnesses, accidents, chronic or recurring problems) *
Does the dog require medication for any temporary or ongoing condition? If so, explain: *
Behavior Profile

It is important that you describe any and all of the dog's behavioral qualities and problems. To place your dog in a permanent and loving home, we need to know as much as possible about his/her good and bad traits.
Is the dog housebroken: *

yes no 100%
If not 100%, estimate %:
How frequently and at what time is the dog used to going outside? *

Please complete the following: *

	Yes	No
Is the dog trained to use a doggie door?
Is the dog crate trained?
Is the dog leash trained?
Has the dog had any obedience training?
Likes to ride in the car?

How does the dog spend his day? Please estimate the percentage of time spent. *

Free run of the house

Confined to one room

Crated

Outside in a pen

Free run of the yard

Free run of the house and yard

Total: 0 / 100
Where does the dog sleep? *
Favorite toys and games? *
Special likes and dislikes? *
How many times a day and when do you feed the dog? *
Brand(s) of canned and/or dry food and amounts? *

Additional information on the dog's behavior: *

	Unknown	Never	Sometimes	Always
Likes/tolerates bath time
Likes/tolerates nail trim
Likes/tolerates grooming
Excessive barking
Separation anxiety
Running away
Toy guarding
Food/treat guarding

How is the dog with cats? *

Good with cats Tolerates them Chases them for fun NOT good with cats DO NOT trust with cats DO NOT TRUST - HAS HIGH PREY DRIVE DO NOT TRUST - HAS KILLED A CAT
How is the dog with other dogs? *

Good with most other dogs Good with smaller dogs only Not good with smaller dogs Good with larger dogs only Not good with larger dogs Not good with any other dogs MUST BE AN ONLY DOG
How is the dog with children: *

Good with all children Good with children 10+ only NOT good with any children Nippy with children Has bitten a child
How is the dog with adults? *

Good Not good Good with women only Good with men only
Has the dog ever bitten a person? *

Yes No
If yes, please provide details: *
If yes, is Animal Control or the Police invlolved? *

Yes No
If Animal Control was involved, please provide their contact information: *
Please provide a copy of all paperwork regarding the biting incident
Any other comments the rescue needs to know about this dog:` *
Terms and Conditions
By checking the following box and/or typing or signing my name, I certify that...
- I am the owner of this animal and hereby relinquesh all present and future rights and claims to the subject animals, and to all possessions transferred with it to Dachshund Rescue of Northern California (DRNC).
- I have fully informed DRNC of all known or suspected medical and/or behavioral problems and concerns with this animal.
- I have indicatd all information possible to ensure the animal's continued happiness and welfare.
- I understand that I may not be provided with information about this animal's whereabouts once surrendered.
- I give the aforementioned Veterinarian, Clinic, and any other Veterinarian/Clinic that has treated this animal for any reason, and their staff permission to discuss this animal with DRNC and provide copies of any and all paperwork with regard to this animal.
I agree to the above Terms and Conditions/Certifications *

yes no
Type your name to "sign" *
BEFORE YOU SUBMIT - did you answere all the questions?

Please check because incomplete forms will be kicked back for completion and delay the process. If a question does not apply to your dog, just type n/a.
Should be Empty:

Surrender Form

Dog's Information

Owner's Information

Veterinary and Medical Information

Spay/Neuter Fee:

Behavior Profile

Terms and Conditions