EmailMe Form - Owner Surrender Form

First Name *

Last Name *

Email *

Address *

City *

State *

Zip *

Home Phone *

### - ### - ####

Cell Phone *

### - ### - ####

INFORMATION ABOUT THE DOG

Dogs Name *

Age *

Gender *

Male

Female

Weight *

Spayed or Netuered *

Yes

No

Up to date on vaccines *

Yes

No

On heartworm preventative *

Yes

No

Is dog good with other dogs *

Yes

No

Unknown

Is dog good with cats *

Yes

No

Unknown

Is dog good with kids *

Yes

No

Unknown

Does the dog have a microchip *

Yes

No

Brand & Number

Is dog kept indoors or outdoors *

Where did you get this dog *

Breeder

Shelter

Rescue

Other

If other, please write in box below how you acquired the dog

Name and Address of Breeder/Shelter/Rescue

Are there any known behavorial problems or health problems

Is dog crate trained *

Yes

No

Does dog have separation anxiety *

Yes

No

If yes, please explain

Has the dog ever bitten anyone *

Yes

No

If yes, please explain

Has the dog ever gotten into a fight or bitten another dog *

Yes

No

If yes, please explain

Why are you rehoming your dog *

How long can you keep the dog while we try to find a home for him/her *

Please provide us with current or previous vets name, address and phone number *

Upload Picture if Available