Dog Release Form
Please fill out what you can below in order to help us give your dog the best medical care and training possible. The more detail you can provide, the more you are helping us in finding the best possible permanent home for your dog.
Type of Release:
Reason for Release:
Your answer
RELINQUISHING PARTY INFORMATION
First Name:
Your answer
Last 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
Preferred Method of Contact:
Preferred day/time to be contacted:
Your answer
DOG INFORMATION
Breed:
Your answer
Name:
Your answer
Color:
Your answer
Weight:
Your answer
Microchip Number:
Your answer
Approximate Age:
Your answer
Gender:
Spayed or Neutered:
Type of Food the Dog Eats:
Your answer
Feeding Times:
Your answer
Where does the dog sleep now?
Your answer
Check all dog behaviors that apply:
Required
Dog's behavior with children:
Your answer
Explain any behaviors that need modified or you feel can be improved upon:
Your answer
VET INFORMATION
If known, please provide the following information about the dog's most recent veterinarian.
Name of Vet's Office:
Your answer
Street Address:
Your answer
City:
Your answer
State:
Your answer
ZIP Code:
Your answer
Phone Number:
Your answer
Last Rabies Shot:
Your answer
Last Heartworm Check:
Your answer
Last Vet Visit:
Your answer
Last Flea Preventative:
Your answer
Last Heartworm Preventative:
Your answer
Known Illnesses:
Your answer
CERTIFICATION
It is understood that WESTIE RESCUE HOUSTON does not buy or pay for dogs. This is a service to help place Westies in new homes when their present owners can no longer keep them. A donation to help pay for expenses is appreciated. Donations are tax deductible and can be mailed to the address at the bottom of the form.
Release (print this form and complete the blanks and sign)
I, hereby release and make available for adoption, the dog named , to WESTIE RESCUE HOUSTON. I certify that I am the owner of this dog, free and clear of all other interests. I certify that this dog is not possessed of any dangerous or vicious propensities, and that I have not willfully concealed information about the dog that might indicate such propensities. The information I have provided about this dog is true and complete. I hereby forever release, discharge and agree to hold harmless and indemnify WESTIE RESCUE HOUSTON and its agents from all claims, demands, actions, causes of action, or liability of any kind whatsoever arising as a result of, or in connection with, the adoption or other disposition of the above named dog. I authorize the Veterinarian's office(s) listed above, to release any medical records of the dog mentioned above, to WESTIE RESCUE HOUSTON, and/or its Assigns and agree to allow them to discuss the medical records of this dog with representatives of WESTIE RESCUE HOUSTON and/or its Assigns and with any future Veterinarian's office to the extent that it is for the express benefit of the dog's health and well being.
Signed By Owner/Releaser:
Your answer
Date:
Your answer
If you have printer access, please print this form and bring with you to the Release Meeting. Double check all fields have been printed properly. If not, make corrections by hand. Printing/Saving to a .pdf format should preserve all form data.

Westie & Scottie Rescue Houston
PO Box 9776
The Woodlands, TX 77387-9776
855-468-7974

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