Owner's Information

*Name:

*Address:

Address 2

*City:

*State

*Zip Code:

*Phone Number:

*Email:

Are you willing to make a contribution to help with veterinarian cost and daily care?
No$25$50Other
Other Amount

Dog Information-General

Name:

Breed:

Gender:
MaleFemale

Age:

Weight:

Is your pet spayed/neutered?
YesNo

Is your pet micro-chipped?
NoYes (Enter number if known)

Dog-Information Behavioral

Does your pet respond to his/her name?
YesNo

How does your pet act at the groomer?

How does your pet act at the vet?

Does your pet urinate when approached?
YesNo

Does your pet engage in self mutilation? (chewing on leg/licking raw spots, ect)
NoYes, please explain

Has your pet ever bitten anyone?
NoYes, please explain

Does your pet climb/jump/dig under/chew through fencing of any type?
NoYes, please explain

Does your pet have anxiety? (separation, gender, storms, loud sounds, ect.)
NoYes, please explain

Does your pet bark excessively?
NoYes, in what situations

Does you pet chase cars, other animals, people ect.
NoYes, please explain

Is your pet aggressive?
YesNo

Does your pet get along with...
CatsOther DogsStrangersChildrenOther

Has your pet ever killed or injured another animal?
NoYes, please explain

Dog Information Medical

What vet do you use?

Is your pet up to date on vaccinations?
YesNo

Does your pet have/had any known medical issues or injuries?

Is your pet currently on any medication?
NoYes, please explain

Is your dog on heart worm preventative?
YesNo

If yes (heartworm preventative), how long have they been on preventative?

Does your pet have any allergies? (medicines, insects, ect.)
NoYes, please list

Dog Information - Training

Is your pet house training
YesNo

Is your pet crate trained?
YesNo

Is your pet leash trained?
YesNo

Has your pet had formal training?
YesNo

Does your pet know any commands?
NoYes, please list

Other Information

Why are you surrendering this dog?

How long have you had this dog?

Where did you get this dog?
ShelterFamily/FriendsBreederOther

Please add a photo of your pet if you have one available.

Please add vet records if you have them avaliable.