Miri’s Haven Owner Surrender Request Form

Owner Surrender Request Form

Miri’s Haven is a foster based rescue. Finding a foster/adoptive home that is a good fit for your dog is very important to us. This means that when you contact us to surrender, we will ask you to answer a series of questions so that our team can work to find an appropriate foster home for your dog. This can sometimes take time and we appreciate your patience as we go through this process. We know that this is a very difficult decision and we are here to help. Please complete all questions accurately and someone will reach out to you after we receive your answers.
Owner’s Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many dogs are you looking to surrender?
please complete a form for each dog
Dog Name(s):*
Dog’s birthday (if known):
Dog Age(s) (estimate is okay)*
Why are you looking to surrender your dog?*
How soon are you looking to surrender your dog?*
Dog breed*
Dog's approximate weight
How long have you owned this dog?*
Where did you get the dog?*
Is your dog spayed or neutered?*

YesNoI’m not sure
Is this dog current on vaccinations?*

YesI am not certainNo
Does the dog have any health problems or is currently on medication?*
Deaf, blind, arthritis etc
When was the last time your dog saw a vet?
Access to any previous medical records is very helpful
What is the name of your dog's vet?
Access to any previous medical records is very helpful
Is your dog friendly when meeting new people?*
Is your dog friendly with other dogs?*
Has the dog ever lived with dogs, cats or children?*

Lived w dogLived w catLived w childenNo
If your dog has lived with children, please select what age ranges the dog is comfortable with:
(Select as many as applicable)
Has your dog ever bitten a person or another animal*

NoYes
If yes, please explain*
How would you describe your dog?*

FriendlyIndependentSnugglyShyQuietBusyNervousPlayfulOther
Is your dog housebroken?*

HousebrokenNoWears DiapersUses Potty Pads
Does your dog currently go for leash walks or do they go out in the yard?
Please describe how your dog behaves on a leash:
e.g., pulling, aggression, slow, wants to run, etc
Is your dog crate trained?:
Please elaborate as necessary
Does your dog have any unusual/specific habits or behaviors we should be aware of?:
e.g: my dog only likes to take their pills in a piece of bread
Is there anything else you want to tell us about your dog?
Please upload a photo or photos of your dog.*

Cancelof
Please upload a clear image of your ID, front and back.

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How did you hear about us?*
Date:*

MonthDayYear
Should be Empty: