SURRENDER

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Personal Information

* First name

* Last name

* Email

* Email confirmation

Home phone

Cell number

* Current Address

Current Address 2

* Zip

* City

* GenderMaleFemale

Country

*State/Province

Date of Birth

* Month

* Day

* Year

DOG'S BASIC INFORMATION

DOG'S BREED

DOG'S AGE

MALE OR FEMALE

MALEFEMALE

NEUTERED OR SPAYED

YesNo

MICROCHIPPED

YesNo

WHERE DID YOU GET THE DOG FROM?

BREEDERPET STOREREHOMING SITEFAMILY MEMBERFRIENDSTRAYSHELTER

HOW LONG HAVE YOU OWNED THE DOG?

WHO IS THE DOG'S VETERINARIAN?

WE WILL NEED ACCESS TO YOUR VETERINARIAN'S INFORMATION TO CONTACT THEM IN ORDER TO CONFIRM MEDICAL STATUS. PLEASE GIVE YOUR VETERINARIAN'S OFFICE PERMISSION TO RELEASE INFORMATION TO OUR SHELTER WHEN WE MAKE THE CONTACT.

IS THE DOG UP TO DATE ON VACCINES?

RABIESDHLPPBORDATELLANOT UP TO DATE

EXSITING MEDICAL CONDTIONS:

THIS INCLUDES ANY DIAGNOSIS BY THE VET (EPILEPSY, FOOD ALLERGY, NEEDED MEDICATIONS, ETC.), PLEASE INCLUDE AS MUCH INFORMATION AS POSSIBLE.

SURRENDER REASON

PLEASE EXPLAIN REASON AS IN DEPTH AS POSSIBLE.

DOG’S NAME

WEIGHT

Exact or best estimate

BEHAVIORAL QUESTIONS

HAS THE DOG SCRATCHED OR BITTEN A PERSON IN THE LAST TEN (10) DAYS?

YesNo

IF YES, WHO WAS BITTEN AND WHAT WAS THE DATE?

HAS THE DOG EVER:

BITTENSCRATCHEDLUNGED OR ATTACKEDNONE OF THESE

IF YES, DID A BITE BREAK SKIN?

YesNo

PLEASE EXPLAIN THE CIRCUMSTANCES OF THE BITE:

IN DEPTH PLEASE

WAS ANIMAL CONTROL INVOLVED OR MEDICAL TREATMENT NEEDED?

ANIMAL CONTROLMEDICAL TREATMENT

PERSONALITY/TEMPERAMENT

CHECK ALL OF THE FOLLOWING THAT DESCRIBE THE DOG:

VERY ACTIVECOUCH POTATOBARKS A LOTQUIETPLAYFULFRIENDLYFENCE JUMPERSHYLIKES TO BE TOUCHEDAFFECTIONATEFEARFULINDEPENDENTPROTECTIVEALWAYS BY YOUR SIDEINDOOR DOGOUTDOOR DOGNERVOUSHOUSE TRAINEDCRATE TRAINEDLEASH TRAINEDLIKES MENLIKES WOMENWORKED LIVESTOCKUSED FOR HUNTINGSEPARATION ANXIETYDIGGER

PLEASE USE THIS AREA TO FURTHER EXPLAIN ANY OF THE CHECKED BOXES (IF NEEDED):

HAS THE DOG LIVED WITH CHILDREN?

YesNo

WOULD YOU RECOMMEND YOUR DOG LIVE WITH CHILDREN IN THE FUTURE?

YesNo

HOW OLD WERE THE CHILDREN IN THE HOME?

HAS THE DOG LIVED WITH CATS?

YesNo

WOULD YOU RECOMMEND YOUR DOG LIVE WITH OTHER CATS IN THE FUTURE?

YesNo

HAS THE DOG LIVED WITH OTHER DOGS?

YesNo

WOULD YOU RECOMMEND YOUR DOG LIVE WITH OTHER DOGS IN THE FUTURE?

YesNo

PLEASE DESCRIBE THE OTHER DOGS IN THE HOME (BREED, SIZE, GENDER):

WHAT ARE THE DOG'S FAVORITE ACTIVITIES OR OBJECTS?

WHAT DOES THE DOG DISLIKE OR FEAR?

WHERE IS THE DOG KEPT DURING THE DAY?

WHERE IS THE DOG SLEEP AT NIGHT?

DOES YOUR DOG TRAVEL WELL IN THE CAR?

YesNo

WHAT TYPE OF FOOD DO YOU FEED YOUR DOG?

DOES YOUR DOG HAVE FOOD AGGRESSION WITH OTHER ANIMALS OR PEOPLE?

PEOPLEANIMALSNONE

DOES YOUR DOG HAVE TOY AGGRESSION WITH OTHER ANIMALS OR PEOPLE?

PEOPLEANIMALSNONE

ADDITIONAL INFORMATION

PLEASE USE THIS SECTION TO INCLUDE ANY OTHER INFORMATION THAT YOU BELIEVE IS IMPORTANT FOR BOTH US AND A FUTURE OWNER TO KNOW ABOUT THE DOG:

PLEASE USE THIS SECTION TO GO IN DEPTH ABOUT ANY BEHAVIORAL ISSUES/QUIRKS THAT THE DOG MAY HAVE:

BLUE CHIP NOTE

While we try our best to assist each family and animal in need, we can not guarentee that your animal will be accepted into our shelter. We reserve the right to deny a surrender form. Please call 570-333-5265 if you have not heard from us within 7-14 days of surrender form completion.

please note - Completing this form does NOT guarantee that we can accept your animal as a surrender.

I have read and agree to the terms and conditions. By checking this box I am confirming that I am 13 years of age or older.

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