Senior Dog Sanctuary Owner Surrender Form

Senior Dog Sanctuary Owner Surrender Form
Date

Month Day Year
Date
Name *
Owner Name vet records under (if not the same)
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
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 *
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
Please list any past or present injuries, treatments or other medical history *
Check all of the following that describe the dog *

Very active Couch potato Barks a lot Quiet Playful Friendly Fence Jumper Shy Likes to be touched Affectionate Fearful Independent Protective Always at your side Indoor dog Outdoor dog Nervous House-Trained Crate-Trained Likes men Likes women Worked livestock Used for hunting Separation anxiety Digger
Has the Dog Lived With Children *

Yes No
What Ages
Would You Recommend For Children in the Future

Yes No
Has the Dog Lived With Other Dogs *

Yes No
Would You Recommend For Dogs in the Future

Yes No
Has the Dog Lived With Cats *

Yes 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 *
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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