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: *
RELINQUISHING PARTY INFORMATION
First Name: *
Last Name: *
Street Address: *
City: *
State: *
ZIP Code: *
Phone Number: *
Email Address: *
Preferred Method of Contact: *
Preferred day/time to be contacted:
DOG INFORMATION
Breed: *
Name: *
Color: *
Weight: *
Microchip Number:
Approximate Age: *
Gender: *
Spayed or Neutered: *
Type of Food the Dog Eats: *
Feeding Times: *
Where does the dog sleep now? *
Check all dog behaviors that apply: *
Required
Dog's behavior with children: *
Explain any behaviors that need modified or you feel can be improved upon:
VET INFORMATION
If known, please provide the following information about the dog's most recent veterinarian.
Name of Vet's Office:
Street Address:
City:
State:
ZIP Code:
Phone Number:
Last Rabies Shot: *
Last Heartworm Check: *
Last Vet Visit: *
Last Flea Preventative: *
Last Heartworm Preventative: *
Known Illnesses: *
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: *
Date: *
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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