Senior Dog Sanctuary Owner Surrender Form

Senior Dog Sanctuary Owner Surrender Form
Date

Month Day Year
Date
Name *
Phone Number *

Area Code Phone Number
E-mail *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Name of Dog *
Age *
Breed *
Weight *
Sex *

Male Female
Spay/Neutered *

Yes No
Microchipped *

Yes No
Microchip Number
How Long Have You Owned the Dog *
How Many Homes Has the Dog Had *
Where Did You Get the Dog *
Reason for Surrender: *
Provide as much information as possible.
When does the dog need placement? *

Month Day Year
Date
Is this date flexible? *

Yes No
Has the dog scratched or bitten a person in the last ten (10) days? *

Yes No
Who Was Bitten
Date & City of Bite
Has the Dog Ever: *

Bitten Scratched Lunged or Attacked None of the above
Did the incident break the skin

Yes No
Was Animal Control Involved

Yes No
Please Explain the Circumstances
Veterinarian Name *
Veterinarian Phone *
Owner's Name Vet Records Can Be Found Under
Date of Last Vet Visit *
Is the Dog Current on Vaccinations *

Yes No
Do you give your veterinarian permission to release your dog's medical records to the Senior Dog Sanctuary of Maryland? *

Yes No
Do you agree to contact your veterinarian(s) and request a copy of your dog's medical records be sent to SDS? *

Yes No
Please list any past or present injuries, treatments or other medical history *
Check all of the following that describe the dog *

Active Medium Energy Couch potato Barks a lot Only chatty sometimes Quiet Playful Friendly Likes to be touched Affectionate Always at your side Shy Independent Fearful Nervous Separation anxiety Protective Indoor dog Outdoor dog Fence Jumper Escape artist Digger Likes men Likes women Worked livestock Used for hunting
Is the dog housebroken? (Select all that apply) *

Yes - outside only Yes - inside on pee pads Yes - a combo of inside/outside Has occasional accidents Not housebroken Incontinent due to age/medical
Is the dog crate trained? (Select all that apply) *

Yes Use when left alone Use at night Dog loves the crate Dog tolerates the crate Dog does not like the crate Dog is destructive in crate Never Exposed/Used
Has the Dog Lived With or Been Exposed to Children *

Lived with Exposed to No
What Ages
Would You Recommend For Children in the Future

Yes No
Has the Dog Lived With or Been Exposed to Other Dogs *

Lived with Exposed to No
Would You Recommend For Dogs in the Future

Yes No
Has the Dog Lived With or Been Exposed to Cats *

Lived with Exposed to No
Would You Recommend For Cats in the Future

Yes No
How Long is the Dog Left Home Alone Each Day *
What does the dog dislike or fear? *
Where is the dog kept during the day *
Where does the dog sleep at night *
How Does the Dog Travel in a Car *

Loves car rides Tolerates them Is anxious Prefers not to go anywhere in the car
What Type of Food Do You Feed the Dog *
Is there anything else a future owner should know about this dog
Please Upload a Clear Picture of the Dog *
My signature below certifies that I am the owner of, or have the authority to surrender to The Senior Dog Sanctuary of MD the animal described above. I certify that to the best of my knowledge I have disclosed all information about the animal concerning health, behavior, history, and anything else that may affect the safe placement of the animal in a new home and that all statements made above are true and correct. I understand once my dog is accepted, the Senior Dog Sanctuary of MD shall have sole and exclusive legal rights to make all outcome decisions deemed appropriate and that SDS shall not communicate the outcome of the animal to me or any other party.
Sign here *

Clear
The Senior Dog Sanctuary of MD provides extraordinary care and covers all food, medical and other expenses for each animal we receive. If you are able, please consider making a donation to help us care for your dog. Thank you!
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