Surrender Intake Form

Surrender Intake Form

Please complete this form to request intake of your dog.
Date

MonthDayYear
Releasing Party*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Releaser Phone Number*

Area CodePhone Number
Releaser E-mail
Dog Information
Dog Name*
Dog Breed*

PugPug MixOther
Sex*

MaleFemale
Coat Color (e.g., Fawn, Black, Brindle etc.)
Approx Age or Date of Birth
Approx. weight of the dog
Spayed or Neutered?*

YesNoNot sure
Microchipped?*

YesNoNot Sure
If you have a photo of your dog, you may upload it here:

Upload a File

Cancelof
What is your timeframe for the intake?*

As soon as possibleWithin 2 weeksAt the rescue's convenience
Veterinarian/Vet Clinic Name
Veterinary Office or Vet Name
Veterinarian/Vet Clinic Phone Number:

Area CodePhone Number
If you have any available vet records, you may upload them here:

Upload a File

Cancelof
When was the dog's last vet visit?

Within the last 6 monthsWithin the last year2 or more years agoNever been to a vet
Is the dog up-to-date on vaccines?

YesNoNot Sure
Is the dog on any medications?*

YesNo
if yes, what medications?
What food is the dog being fed & amount
Dog Habits and Personality
Is the dog house trained?

YesNoExperiencing issues
Is the dog crate trained?

YesNoHas never been crated
Where does the dog sleep?
How does the dog do on a leash?

Good on leashPullsIs leash reactiveHas never been on a leash
Has the dog ever bitten anyone?*

NoYes
If 'Yes', please explain:
Temperament around kids?

Good with kidsNot good with kidsHas not been around kids
Additional info about temperament around kids:
Temperament around other dogs?

Good with other dogsGood with some other dogsNot good with other dogsHas not been around other dogs
Additional info about temperament around other dogs:
Temperament around cats?

Good with catsNot good with catsHas not been around cats
Additional info about temperament around cats:
Please provide reason for surrendering the dog:*
Is there anything else we need to know about the dog?:
Surrender Intake Agreement
I confirm that I am the sole owner of this dog and have the full and legal right to release said dog to Pacific Pug Rescue*

I agree
At the Actual Time of Release:

Pacific Pug Rescue will require a signed release agreement form from the Releasing Party to be completed.
Should be Empty:

Surrender Intake Form

Dog Information

Dog Habits and Personality

Surrender Intake Agreement

At the Actual Time of Release: