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Dog Surrender Form
Please fill out as accurately and honestly as possible, so we are able to find the perfect fit for your dog.
Your Name: *
Your answer
Street Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Phone Number: *
Your answer
Email Address *
Your answer
General Information
Dog's Name *
Your answer
Dog's Breed: *
Your answer
Dog's age or approximate age *
Your answer
Dog's gender *
Dog's Color *
Your answer
Is your dog spayed/neutered? *
Does your dog have a microchip? *
Has your dog bitten anyone or any animal in the last ten (10) days? *
Has your dog bitten anyone or any animal and drawn blood? *
Name and phone number of vet clinic: *
Your answer
History
What would you like new owner to know about this dog? *
Your answer
Why are you rehoming this dog? Please provide as much detail as possible. *
Your answer
If we could help resolve this issue would you be interested in keeping the dog? *
How long have you owned your dog? *
Your answer
Including yours, how many homes has this dog had? *
Your answer
Where did you acquire this dog? *
How often did your dog see a veterinarian? *
How did the dog react going to vet? *
Your answer
Are there places on the dog's body he/she does not like being touched, brushed, or petted? *
If above question was yes, please tell where dog does not like being touched, brushed or petted. *
Your answer
Does you dog have any allergies or sensitivities? *
If above question was yes, please list allergies or sensitivities. *
Your answer
Home Life, Training & Manners
How would you describe your dog most of the time? (check all that apply) *
Required
Where was the dog when no human members of your family were at home? *
What areas did the dog have access to? *
Housetraining: (check all that apply) *
Required
Can this dog be left alone in the house for 8 hours a day without issues? *
Is the dog destructive if left alone inside the home? *
Please tell us about the desirable tricks and habits you have taught your dog to do: (check all that apply) *
Required
What words does your dog understand? (Check all that apply) *
Required
Is the dog protective or possessive? *
Please check all the animals that the dog has lived with: *
Required
Would you recommend placing this dog in a home with other dogs? *
Describe your dog's play style with other dogs. (check all that apply) *
Required
Would you recommend placing this dog in a home with a cat? * *
Please check all of the following that frighten this dog: *
Required
Would you recommend this dog be around children regularly? * *
Has the dog done any of the following with adult family members? *
Required
Has the dog done any of the following with children? *
Required
Has the dog done any of the following with strangers at the door? *
Required
Has the dog done any of the following with visiting adults? *
Required
Has the dog done any of the following with visiting children? *
Required
Has the dog done any of the following with a vet or groomer? *
Required
Has the dog done any of the following with people near his/her sleeping area? *
Required
Has the dog done any of the following with pedestrians? *
Required
Has the dog done any of the following with people near his/her food? *
Required
Has the dog done any of the following with people in uniform? *
Required
Has the dog done any of he following with wildlife? *
Required
Has the dog done an of the following with all dogs? *
Has the dog done any of the following with same sex dogs? *
Has the dog done any of the following with cats? *
Required
Ownership *
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