Please let us know about your dog. The information will help us in finding a good new home for your pet. Dog Information for Surrender The dog's name is* Where did you get the dog?* How long have you had the dog?* Reason you are giving the dog up* How old is the dog?* What breed is your dog?* Gender* Male Female Is the dog spayed or neutered?* Where does the dog stay during the day? In Out Both If he sleeps inside, where does he sleep? Dog Bed Furniture Your Bed Other Where? How is the dog confined? 4' fence 5' fence 6' fence Chain Cable Kennel Invisible fence Only goes out on leash Is the dog house-trained? Yes No If house-trained, how often does the dog need to go out? If your dog has accidents, is it only when left alone? Yes No Medical InformationDoes your dog have a microchip? Yes No Your dog's vet clinic information:*Please provide: Name of the clinic, address and phone number. Is your dog on medication or have any medical conditions?* Is your dog current on vaccinations?*It is required that you bring in your dog's current records during surrender. Does your pet have any of the following conditions?* Allergies Prescription Dietary Needs Diabetes Heart Murmur Heart Disease Arthritis Dental Issues Heartworms Parvo Kidney Disease Cancer None of the above Personality QuestionnairePlease give details on your pet's personality so staff can understand the best fit for their new home. Check all that apply to describe your dog's personality: Select All Friendly Independent Shy Active/Hyper Quiet Protective Nervous Calm Submissive Dominant Loves to play Loves toys Affectionate Couch potato What is your dog afraid of? Where is your dog sensitive about being handled? (example: ears, feet, etc.) Does your dog destroy things in the house or yard? Yes No What items? How often? Has your dog ever lived with children? Yes No If he has ever lived with children, what ages? Is your dog good with those children (friendly, tolerant)? Yes No If he is not good with children, please explain. If your dog doesn't live with children, how often does he/she interact with children? What does your dog do if:a child is crying/screaming? a child touches or pets him/her? he/she sees a child on a bike? he/she sees a child running? Has your dog ever growled at you or anyone else?*YesNoIf your dog has ever growled at you or anyone else, please explain the situation.* Has your dog ever snapped at you or anyone else?YesNoIf your dog has ever snapped at you or anyone else, please explain the situation.* Has your dog ever bitten (broken skin) you or anyone else?*YesNoIf your dog has ever bitten (broken skin) you or anyone else, please explain the situation.* What other animals has your dog lived with? Dogs Cats Other Please specify. If applicable, does he/she do well with the house cat/s? Any issues? If applicable, does he/she do well with the other dog/s? Any issues? How does your dog react when he/she sees an outdoor cat? How does your dog react when he/she sees a small animal like a squirrel? How does your dog react when he/she sees another dog outside? Is his/her behavior different when on compared to when off leash when seeing another dog? How does your dog act at the dog park? Has your dog ever fought with another dog? Yes No Has your dog ever injured another dog? Yes No Does your dog: (please mark all that apply) Run away Bark too much Jump up on people Dig in the yard Other Please specify What does your dog do when:A stranger/visitor knocks on the door? A stranger/visitor comes into the house? A stranger approaches you on a walk? You or someone else goes near the food bowl when he/she is eating? You or someone else tries to take away toys or a dog treat? You or someone else gives him/her a hug? You or someone else reprimands him/her? Have you or has someone else trained him/her? Yes No Have you or has someone else ever taken your dog to a training class? Yes No What kind of training have you tried? Choke chain Electric shock Treats Praise Clicker What commands does he/she know? Sit Down Stay Come Shake Roll over Other What is your dog's favorite game or toy? What is your dog's best quality? What is your dog's worst quality? Is there anything else we should know about this dog? By checking this box you are adding your signature to this document, and are agreeing that all of the above information is correct to the best of your knowledge.* I agree Name First Last Address* Street Address City State / Province / Region ZIP / Postal Code Email PhonePlease allow 24-48 hours for review. Owner surrenders take place Monday through Friday.* I agree
