Dog Surrender – Speaking Of Dogs

Your Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone number(s) *

Name of Dog *

Are you the dog's legal owner? *

Yes
No

If you are not the legal owner, what is your connection to the dog? *

Where did you get your dog from? *

Please provide the name of the humane society or rescue group *

If Other, please provide further information *

Reason for surrender *

The dog's breed *

Dog's gender *

Male, not neutered
Female, not spayed
Male, neutered
Female, spayed

The dog's age *

Dog's weight (or approx. weight) *

How long have you had the dog? *

Is your dog current (up-to-date) on the rabies vaccine *

Yes
No
I don't know

Is your dog current (up-to-date) on the parvovirus and distemper vaccine? *

Yes
No
I don't know

Is your dog microchipped? *

Yes
No
I don't know

Can you provide health records for the dog? *

Yes
No
I don't know

Does your dog have any ongoing medical conditions or requirements? If yes, please explain. *

Name of veterinarian and/or clinic *

Phone number of veterinary clinic *

Is your dog fully house trained? *

Yes
No

Is your dog pee pad trained? *

Yes
No

Is your dog crate trained? *

Yes
No

At home, is your dog always kept: *

Indoors
Outdoors

Where is your dog kept when no one is home? *

Where does your dog sleep at night? *

Is your dog vocal when left alone? *

Yes
No

Is your dog destructive when left alone? *

Yes
No

Is your dog good in the car? *

Yes
No

Is your dog fearful of being groomed/touched? *

Yes
No

Can you clip your dog’s nails? *

Yes
No

Is your dog ok with you administering ear or eye drops? *

Yes
No

Is your dog good with cats? *

Yes
No

Is the dog currently living with a cat? *

Yes
No

Is your dog good with other dogs? *

Yes
No

Is the dog currently living with another dog? *

Yes
No

Does your dog currently frequent off-leash dog parks? *

Yes
No

Is your dog good with children? *

Yes
No

Is the dog currently living with children? *

Yes
No

What ages are the children? *

Is your dog fearful of strangers? *

Yes
No

Does your dog jump fences? *

Yes
No

Does your dog walk well on leash? *

Yes
No

Does your dog pull and lunge when walking on leash? *

Yes
No

Is your dog friendly with new people/strangers? *

Yes
No

Has your dog had any obedience classes? *

Yes
No

Has your dog ever bitten a human? *

Yes
No

Has your dog ever bitten another dog? *

Yes
No

Does your dog protect/guard toys, food, treats or other items? *

Yes
No

How does your dog react to dogs when on a walk? *

Doesn't care/barely notices them
Friendly and pulls to see other dog
Barks and/or lunges
Calmly approaches to sniff

Can your dog go up and down the stairs? *

Yes
No
Yes, but not easily

How often does your dog go for walks and for how long each time? *

What commands does your dog know (e.g. sit, down, come)? *

How many times per day does your dog get fed? *

Once
Twice
Three times
Has food in bowl all the time

What food is your dog currently eating? *

Any other information you would like to share about your dog? (For example personality, past experiences, etc.) *

What type of home and lifestyle would best suit your dog? *

File Upload - photo 1

Click or drag a file to this area to upload.

Please upload a photo of the dog

File Upload - photo 2

Click or drag a file to this area to upload.

Please upload a second photo of the dog, different from the first

File Upload - photo 3

Click or drag a file to this area to upload.

We would prefer a third photo, if possible

Are you willing/able to make a donation to our organization? (not mandatory) *

Yes
No

How did you hear about our rescue?

If other, please indicate how your heard about us