Surrender Form for PHA

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This form ensures that the rescue organization gets all the necessary information about the dog, including medical and behavioral details, and allows for smooth communication with the veterinarian.

Name *

Address

Email *

Best Phone Number

Dogs Name *

Breed

Age and birthday if known *

Color

Sex?, Spayed or Neutered?

Health and Medical history we should know about? *

Current Veterinarian? *

Is the dog up-to-date on vaccinations?

Has the dog been treated for any medical conditions?

Any ongoing medical treatments or medications?

Does the dog have any allergies?

Behavior and Temperament:

Is the dog house trained? *

Does the dog have any behavioral issues? *

Is the dog good with children?

Is the dog good with other dogs? *

Is the dog good with cats? *

Does the dog have any fears or phobias?

Reason for Surrender:

☐ Relocation☐ Financial Constraints☐ Health Issues☐ Time Constraints☐ Behavioral Issues☐ Other (please explain): *

Additional Information:

Please provide any additional information you feel would be helpful for the rescue:

Signature of Surrendering Owner: *

Date *

YYYY

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