Shelter Surrender Form

Dogs Name

Gender

Age of Dog / Year of Birth

Is this dog Spayed or Neutered?

Is this dog housebroken?

Veterinarian / Clinic Information. Please give name, address, phone number, and (optional) email address.

Do we have permission to contact your vet?

What is the date of your dog's last heartworm test? What were the results of that test?

Please list the date and type of vaccinations your pet last received. (Rabies, Distemper, Bordatella, etc)

Date and result of last fecal specimen.

Date and result of last heartworm test.

Please give the date and brand of the last heartworm preventative you gave your dog.

Does your dog have health issues? If so, list them here.

Does your dog take medications? If yes, list and describe here.

Does your dog have a microchip?

Microchip number

Why do you want to give you Golden up for adoption? Please be as specific as you can.

When (year) and where (breeder, shelter, store) did you get your dog?

What is your dog's energy?

Can you take food away from your dog while he's eating?

Can you take food out of his mouth?

Can you take a toy away from your dog?

Can you grab your dog by his collar?

Can you handle your dog's feet?

Does your dog like to swim?

Does your dog like to go for car rides?

What terms would you use to describe you dog? Mark all that apply:

Other Descriptions of your Dog:

Does your dog? (Check all that apply)

If loose outdoors, how hard is it to get your dog to come back to you?

Where does your dog spend most of his time?

Anything else we should know about your dog's behavior?

Tell us about your dog (personality, etc)

What does your dog like?

What does your dog dislike?

Is your dog afraid of anything?

Do thunderstorms scare your dog?

Do loud noises (fireworks, etc) scare your dog?

How does your dog behave around other dogs?

How does your dog behave around cats?

How does your dog behave around children?

How does your dog behave around strangers?

What does your dog do if another dog approaches while he has a toy he's playing with?

What does your dog do if another dog approaches while he is eating?

Has your dog had obedience training? If yes, describe.

How much time does he spend alone each day? Where is the dog when he is alone?

How do you exercise him? Describe.

Has your dog ever growled at anyone? If yes, describe

Has your dog ever bitten anyone? If yes, describe.

What does your dog eat?

What is his daily routine?

Anything else we should know about your dog, or your reasons for surrender?

I/we hereby authorize use of disclosure of our pet's health information to GRRACE, Inc. [Golden Retriever Rescue and Community Education, In.] and its representatives. Its address: P.O. Box 513, Plainfield, IN 46168. The specific information that should be disclosed is: All medical records, including but not limited to, charts, diagnostic test results, lab reports, x-rays, veterinarian orders, nursing notes, all hospital records, medical bills, correspondence and all other materials contained in pet's medical files. This release shall also allow for the provider identified previously in this form to speak with representatives/volunteers with GRRACE, Inc. I/We may revoke this authorization by notifying the veterinarian identified above, in writing, of my/our desire to revoke it. However, I/we understand that any action already taken in reliance on this authorization cannot be reversed, and my/our revocation will not affect those action.

I, being the owner of the dog listed above, hereby guarantee that all information stated above, in relation to this dog's history with regards to biting, growling, or any other act of aggression, has been accurately described above. I understand that should GRRACE Inc. take ownership of the dog and should determination ever be made that the biting/growling history of this dog be proven to have been misrepresented, then I will be solely responsible for any costs, attorney fees, and medical/surgical bills resulting from my misrepresentation of the dog's prior history. I certify that I am the sole owner of this dog (if there are co-owners, all co-owners must also agree to this document). I understand and agree to the above conditions in this document.