Owner Surrender Form

We understand that surrendering your beloved dog is a difficult decision, and we appreciate you entrusting us with this sensitive process. Your answers to this questionnaire will play a crucial role in helping us find the best possible home for the dog. If there is anything you’re unable to answer, please type “unknown” and proceed to the next question.

Owner’s Information

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Email

Dog’s Information

Name of Dog

Breed/Mix

Age

Gender(Required)

Male

Female

Colors/Markings

Weight

Is the dog spayed/neutered?

First Choice

Second Choice

Third Choice

Is the dog microchipped?

Yes

No

Where did you obtain the dog from?

(breeder, shelter, rescue, friend, etc.)

Health and Medical History

Is the dog up-to-date on vaccinations?

If so, please email records to [email protected] or provide a hard copy in-person to the rescue representative meeting you.

Yes

No

Known Medical Conditions or Health Issues

Does the dog have any known medical conditions or health issues? If yes, please provide details.

Daily Medications or Supplements

Does the dog take any medications or supplements on a daily basis? Include over-the-counter items.

Past Serious Illnesses or Injuries

Has the dog been treated for any serious illnesses or injuries in the past? If yes, please share anything we should know to keep them safe.

Feeding Preferences

What kind of food do you feed your dog at home? How much per day and how often?

Important: Please send your dog to us with a gallon-sized ziplock bag of their current dog food. Immediately changing dog food from one kind to another without a slow transition period often causes stomach upset, stress gastritis, loose stools and sometimes diarrhea. We want their transition into the rescue to be as comfortable as possible.

Behavior and Temperament

How does the dog interact with adults?

How does the dog interact with children?

How does the dog interact with other dogs?

How does the dog interact with cats or other small animals?

Is the dog house-trained?

Yes

No

Is the dog crate-trained?

Yes

No

Behavioral Issues

Does the dog have any behavioral issues (separation anxiety, aggression, fearfulness, etc.)? If yes, please provide details.

Resource Guarding

Have you observed any resource guarding? For example, if a person or animal gets too close to their food bowl or favorite treat, do they communicate by showing their teeth, grumbling, growling or barking?

Biting History

Has the dog ever bitten a person or another animal? If yes, please provide details.

Daily Routine and Care

How much exercise does the dog typically receive each day?

Where does the dog sleep at night?

How does the dog react to being left alone?

Do they howl, bark or whine? Do they become destructive and begin to chew on things?

Does the dog have any favorite toys or activities?

Additional Information

Why are you surrendering the dog?

What kind of home environment do you think would be best for the dog?

Is there anything else you would like us to know about the dog?

Signature(Required)

I certify that the information provided is true and accurate to the best of my knowledge.

Date

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