Owner Surrender Application

*indicates required field

Owner Information

First name*

Last name*

Age*

Address*

City*

State*

Zip*

Phone number*

Email*

Pet Information

Name*

Breed*

Date of Birth*

Weight*

Color*

Spayed/Neutered?*

Upload a photo of the dog here:

Veterinary Information

Veterinary/doctor name*

Address*

City*

State*

Zip*

Phone number*

Last appointment (approx.)

Surrender Information

Reason for surrender?*

For how long have you owned the dog?*

Where did you get the dog from?*

If from a rescue/shelter, does their contract stipulate return to them?

Is the dog bonded with another dog(s)?*

If yes, are you surrendering the other dog(s)?

Behavioral/Bite History

Does the dog exhibit aggressive behaviors such as growling, snapping, etc.?*

What triggers the dog to growl/snap/bite?

Has the dog ever bitten anyone?*

If yes, in the past 10 days?

If yes, who was bitten?

How bad was the bite (nip, bite, skin broken, flesh torn required stitches, etc.)?

What were the circumstances for the dog biting?

How long has this behavior been happening?

Does the dog have any known neurological disorders?*

If yes, what is the prescribed treatment and/or medications?

Is the dog protective of food or toys?*

Is the dog afraid of, or drawn to, men versus women?*

Is the dog afraid of children?*

If yes, will the dog try to bite a child?

Any unusual personality traits or habits?*

Is the dog afraid of anything (thunderstorms, loud noises, etc.)?*

Is the dog affectionate? If so, describe how so? (lap dog, snuggler, loves everyone, loves owner only, can be hugged/held)*

Any areas sensitive to touch (doesn’t like feet touched, etc.)?*

What commands, if any, does the dog respond to? *

What type of household do you feel the dog would do best in?*

Medical and dietary

Is the dog current on the rabies vaccine?*

If yes, do you have the certificate and date?

Has the dog been vaccinated for other things? (Distemper, Parvo, Lepto, Lyme, Bordetella, etc.)*

When is the dog due for vaccines?

Has the dog received a dental cleaning in the past three years?*

Does the dog have any medical problems?*

Please list all medications, dosage, and frequency.

If the dog is on heartworm preventative, which one? (Heartguard, other)*

If yes, date of last pill?

If the dog is on flea/tick preventative, which one?*

If yes, date of last dose?

What brand / type of food does the dog eat?*

What brand treats does the dog eat (if any)?

Does the dog have any food allergies or intolerances?*

Does the dog have a sensitive stomach?*

General Interaction

How is the dog accustomed to being exercised? (fenced yard, walks on leash, walks off leash, invisible fence, dog park, other)*

If walked on leash, how does the dog react to seeing other dogs, people, children?

Has the dog lived with children?*

If yes, how young were the children?

Does the dog like children?*

How does the dog react to strangers?*

Explain behavior at the groomer, any special needs or sensitivities.*

Does the dog get along with other dogs?*

Has the dog lived with other dogs?*

Has the dog ever attended doggie day care?*

If yes, how was his behavior?

What breed/size dogs has your dog been exposed to?*

Has the dog lived with cats?*

Does the dog get along with cats or will it chase them?*

Any other animals the dog is comfortable with or reactive to?*

House Manners

Is the dog housebroken?*

Does the dog use pee pads?*

Does the dog mark in the house?*

For how long can the dog be left alone loose in the house without going potty?*

Is the dog destructive in the house?*

Does the dog use a crate?*

Does the dog prefer a crate?*

Where does the dog stay during the day? (in house, outside, crated, basement, other)*

Where does the dog stay at night?*

Where is the dog kept when no one is home?*

Is the dog allowed on the furniture? If not, is the dog trained to stay down?*

Is the dog allowed on the bed? If not, is the dog trained to stay down?*

Is there anything else we should know to ensure the best fit possible with his/her new family?

Applicants certify that the information provided in this Owner Surrender Application is true and accurate. Any misrepresentation with this surrender application or omission of certain information may result in the application being denied. Misrepresentation and/or omission will invalidate any future contracts.

Signature*

By checking this box and typing my name below, I am electronically signing my application.*
Full Legal Name*

Date*