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OWNER SURRENDER FORM

This form is ONLY for owners of Dogs.
If you are a shelter or rescue, please go to our Agency Intake Request form.

Owner Surrender

1Current Owner Information

2Dog Basics

3Routine

4Disposition

5Medical

6Authorization

Dog's Name
First Name
Last Name
eMail Address
eMail Address Confirm eMail Address
Street Address
Suite or Unit Number
City
State/Province
ZIP/Postal Code
Country
- Phone
Initial Method of Contact
- Method*
- Please Explain:*
- Notes
History
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Dog Default Status: Submitted
- Are you the legal owner of the dog?
  - Yes
  - No
- Please Explain*
- Are you the only owner of the dog?
  - Yes
  - No
- Please Provide Other Owner's Name:
- Other Owner's Phone #
When Did You Get The Dog? (approximate if necessary)
Month
Day
Year
How Long Have You Had This Dog?
- How Was The Dog Obtained?
- Please Explain
- Breeder's Name (if Known)
- Have They Been Notified?
  - Yes
  - No
- Why Not?
- Owner of Dog's Sire (If Known)
- Why Are You Giving Up The Dog?
- Please Explain
- Please Explain The Behavior Issues
- Please Explain The Health Issues
- Please Explain Care Needed
- This field is hidden when viewing the form
  How Many Homes Has This Dog Had?
Veterinarian Information
Do You Have a Veterinarian?
- Yes
- No
Name of Clinic
Name of Vet
Street Address
Suite or Unit Number
City
State
ZIP
Phone

- Dog's Registered Name (If Purebred)
- Dog's Registration Number (If Known)
- Primary Breed
- Breed Name
- Secondary Breed
- Breed Name
- Primary Color
- Which Color?*
- Secondary Color
- Which Color?*
Gender
- Male
- Female
Dog's Date of Birth (If Known)
Month
Day
Year
Weight
Energy Level
- Good With Kids?
- Good With Dogs?
- Please Explain*
- Good With Cats?
- Good With Small Animals?
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Good With Livestock?
Is Dog Trained?
- Are There Any Special Needs (Medical)?
  - Yes
  - No
- What Special Needs(Medical)?
  Select All That Apply
- Are There Any Special Needs (Emotional)?
  - Yes
  - No
- What Special Needs (Emotional)?
  Select All That Apply
- Brief Description of the Dog
Long Description of the Dog
Featured Image
Accepted file types: jpg, jpeg, png, gif.
750 Wide x 750 High in Pixels
Additional Photos of The Dog
Drop files here or

Accepted file types: jpg, gif, png, jpeg, Max. file size: 1 MB, Max. files: 3.
Upload Photos of the Dog (minimum of 3 - include one head shot, one full body) and 750 Wide x 750 High in Pixels

Eating
- This field is hidden when viewing the form
  How Often Is The Dog Fed?
- Does Dog Eat Wet Or Dry Food (Or Both)?
- What Type Of Wet Food Does The Dog Eat?*
- How Much Wet Food Does The Dog Eat?*
- What Type Of Dry Food Does The Dog Eat?*
- This field is hidden when viewing the form
  How Much Dry Food Does The Dog Eat?*
- What Type Of Wet Food Does The Dog Eat?*
- How Much Wet Food Does The Dog Eat?*
- What Type Of Dry Food Does The Dog Eat?*
- How Much Dry Food Does The Dog Eat?*
- What Ingredients?*
- How Much?*
Is Dog A Good Eater?
Does Dog Steal Food From Table/Counters?
Sleeping
- Which Room Does Dog Normally Sleep In At Night?
  Select All That Apply
- Please Describe*
- What Does Dog Use For A Bed?
  Select All That Apply
- Please Describe*
- Is Dog Allowed On Furniture?
Grooming
- This field is hidden when viewing the form
  How Often is Dog Bathed?
- This field is hidden when viewing the form
  Please Describe:
- This field is hidden when viewing the form
  How Often is Dog Groomed?
- This field is hidden when viewing the form
  Please Describe:
Does Dog Mind Baths/Grooming
Does Dog Mind Toenails Clipped
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Does Dog Mind Ears Cleaned

Dog & People
- Is Dog A One Person Dog?
- Does Dog Like Men?
- Please Explain*
- Please Explain*
- Does Dog Like Women?
- Please Explain*
- Please Explain*
- Does Dog Prefer Men?
- Please Explain*
- Does Dog Prefer Women?
- Please Explain*
- Does Dog Jump On People?
Is Dog Friendly With Strangers?
Is Dog Good With Other Animals?
Is Dog Good With Kids?
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Does Dog Like Kids Under 6?
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Does Dog Like Kids 6-10?
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Does Dog Like Kids Over 10?
Is Dog Good with Male Dogs?
Is Dog Good with Female Dogs?
Dog's Temperament
Select All That Apply
How Are Dog's Social Skills?
Select All That Apply
Training
Does Dog Know Basic Commands?
Select All That Apply
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Is Dog Obedience Trained?
Is Dog House Trained?
Is Dog Crate Trained?
Is Dog Leash Trained?
How Does Dog React on Walks?
Select All That Apply
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Does Dog Know How To Use A Doggie Door?
Does Dog Have Occasional Accidents?
Does Dog Tear/Chew Furniture Or Carpet?
Can Dog Be Left Uncrated?
Does Dog Dig?
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Does Dog Know How To Swim?
Does Dog Jump Fences?
Does Dog Escape?
Does Dog Ride Well In The Car?
Barking
- This field is hidden when viewing the form
  Does Dog Bark At Noises?
- Does Dog Bark At Someone At The Door?
- Does Dog Bark Excessively?
Fear & Agression
- Does Dog Exhibit Submissive Behavior?
- Please Describe*
- Please Describe*
- Does Dog Exhibit Aggressive Behavior?
- Please Describe*
- Please Describe*
- Does Dog Guard Food?
- Please Describe*
- Please Describe*
- Does Dog Guard Other Resources (Toys, People, etc.)?
- Please Describe*
- Please Describe*
- Is Dog Shy?
- Please Describe*
- Please Describe*
- Is Dog Fearful Of Strange Noises/Storms?
- Please Describe*
- Please Describe*
- Has Dog Ever Bitten Anyone?
- Please Explain*
- Has Dog Otherwise Attacked Anyone?
- Please Explain*
- Has Dog Attacked Another Animal (Dog, Cat or Other)?
- Please Explain*
- Is there anything else you would like to let us know about the dog's disposition?

Medical: MicroChip Information
Is Dog MicroChipped?
- Yes
- No
- Unknown
- MicroChip Company (If Known):
- Other Company Name:*
- MicroChip Number (If Known):
Vaccination
Is The Dog Up To Date On Core Vaccines?
- Yes
- No
- Last Rabies
- Length of Time:*
  - 1 Year
  - 3 Years
- Serial Number:
- Tag Number:
- This field is hidden when viewing the form
  Next Rabies
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Last DHPP
This field is hidden when viewing the form
Next DHPP
Last Corona
Next Corona
Last Bordetella
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Next Bordetella
Last Lepto
This field is hidden when viewing the form
Next Lepto
Last CIV
This field is hidden when viewing the form
Next CIV
Last Lyme
Next Lyme
Last Giardia
Next Giardia
Last Brucellosis
Next Brucellosis
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Exam Dates
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Last Wellness Check
This field is hidden when viewing the form
Next Wellness Check
- Last Heartworm Test
- Heartworm Results
  - Positive
  - Negative
- This field is hidden when viewing the form
  Next Heartworm Test
- Last 4DX
- Heartworm
  - Positive
  - Negative
- Lyme
  - Positive
  - Negative
- Ehrlichia Canis
  - Positive
  - Negative
- Ehrlichia Ewingi
  - Positive
  - Negative
- Anaplasma Phagocytophilum
  - Positive
  - Negative
- Anaplasma Platys
  - Positive
  - Negative
- Next 4DX
- Last Fecal
- Results*
- Date 1
  Dates medication given/started for positive Fecal Flotation Test result(s) above or for prophylactic deworming of negative fecal result.*
- Date 2
- Date 3
- Next Deworming Treatment
- Next Fecal
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Flea & Tick
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Medication
This field is hidden when viewing the form
LAST DATE
Date Flea/Tick Preventative Given
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NEXT DATE
Next Flea/Tick Treatment (Flea/Tick preventatives are due once a month unless the dog is on Bravecto which is given every 3 months.)
Spay Neuter
Has The Dog Been Spayed/Neutered?
- Yes
- No
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How Did You Tell?
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Please Describe
<p>Stated By Previous Owner</p>
Medical & Dental Issues
Past Medical Issues
Past Dental Issues
Known Allergies
Add Allergies

Notes
Is there anything else you would like to let us know?
In your opinion, what would be the best type of home situation for this dog?
Signature
Authorization: I hereby represent and warrant each of the following: (a) that I am the rightful owner/keeper/caretaker/custodian of the dog (b) that I have authority to convey, surrender and relinquish the dog, (c) that I am hereby willfully surrendering and releasing any and all of my property rights to the dog, (d) that no other person has a right of ownership or property to the dog, (e) that upon surrender the dog may not be returned to me. I have read and understand the terms of this Surrender From.*
- Yes
Phone
This field is for validation purposes and should be left unchanged.

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