Surrender Form
First Name *
Last Name *
Street Address *
City *
State/Province *
Zip/Postal Code *
Email *
Home Phone *
Cell Phone *
Is your dog up to date on rabies vaccination? *
Is your dog up to date on DHLPP vaccination? *
Does your dog receive heartworm preventatives?  *
Does your dog receive flea and tick control? *
Veterinarian/Practice Name
Veterinarian's Phone
Dog's Name
Is your dog male or female? *
Is your dog spayed or neutered? *
Please provide your dog's birth date. If you cannot provide that, please tell us the age of your dog *
How much does your dog weight? *
What breed is your dog?
Where did you get your dog?
When did you get your dog?
Is your dog good with others? Please select all that apply:
Has your dog ever injured another person? If so, please describe the circumstances:
 *
Has your dog ever injured another animal? If yes, please describe
 *
Does your dog have any injuries or illnesses? Please describe.
 *
Please describe your dog’s personality and traits. Select all that apply:
 *
Required
Why are you surrendering your dog?
 *
Anything additional we should know about your dog?
I have read and answered each question on this Owner Surrender Form and have provided truthful answers. I am providing consent to GSDHCEC to contact my Veterinarian for further information if needed. Submission of this form provides a signature.
 *
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