DOG OWNER SURRENDER INFORMATION SHEET
This sheet is designed to help place your dog into an appropriate home. PLEASE BE HONEST. The information you provide will help potential adopters make an accurate decision as to whether your dog will fit into the environment they can provide.
Sign in to Google to save your progress. Learn more
Name: 
Phone Number: 
Appointment Day and Time: 
Name of Pet:
Does your dog have a nickname? 
Animal Number (office use only)

How old is your dog? 

Is your dog male or female?
Clear selection
Is your dog spayed or neutered? 
Clear selection
If female and not spayed when was the last heat cycle?
Could your dog possibly be pregnant?  
Clear selection
How long have you had this dog? 
Where did you get the dog? 
What specifically influenced your decision to surrender the dog?
Is your dog house-trained?  
Clear selection
  How does your dog let you know that it needs to go out?   
Has your dog ever used a crate? 
Clear selection
-If so, what kind (wire or plastic)? 
-How does your dog do in the crate? 
-How much time does your dog spend in the crate? 
Does your dog:
-Dig in the yard? 
Clear selection
-Jump on people?
Clear selection
-Enjoy riding in the car? 
Clear selection
-Bark too much? 
Clear selection
-Run away? 
Clear selection
-Know any tricks? 
Clear selection
-If so what?

-Exhibit any fearful behavior (thunder/loud noises/men/loud voices, certain people, etc.)?

Clear selection
-If yes, what and how severe is it? 
When you are gone, where is your dog?  
-If restricted to a room, what room?
If you have a fenced-in yard, what type of fencing? 
-How high is your fence? 
-Can your dog jump over the fence?  
Is your dog outside supervised or unsupervised? 
-When outside are they:
Has your dog been around children
Clear selection
How does your dog react around children? 
What are the ages of the children living in the household?
How does your dog greet strangers at your house? 
What kind of play does your dog like? 
Do you play tug of war with your dog? 
Do you rough house with your dog? 
Has your dog ever growled, nipped or shown aggression to any person or other animal? 
-Please describe in detail the situation how and where this occurred 
Has your dog lived with or been around cats?  
-If yes, how did it react? 
Has your dog lived with or been around other dogs?  
- If yes, how did it react? 
What words best describe your dog?  
What form of correction or discipline have you used with your dog? 
- How did your dog react? 
Have you ever consulted a trainer or behaviorist on ANY problems concerning this dog? 
- What kind of problem? 
Who is your dog’s veterinarian? 
- When was your dog last seen by vet? 

Is your dog current on vaccinations? 

Whose name are the records under?
Are there any health issues (current or past) we need to be aware of?  
-If yes, please explain 
What do you feed your dog? 
-How often? 
-How much? 
Does your dog get people food? 
Where does your dog sleep? 
Does your dog like to be brushed? 
What kind of exercise does your dog get? 
-How often
How does your dog walk on a leash? 
Clear selection
Would you say your dog’s energy is  
What does your dog love doing the most? 
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms