Dog Owner Surrender Form printable pdf download

Canine Surrender Form

Staff:

Date:

Please consider making a tax deductible donation now to help us care for your pet during his/her stay with us. This

donation will go to cover food, shelter, medical and other expenses.

We are dedicated to finding the best possible home for your animal. To do this effectively, we rely on you to provide

us with accurate information. Please answer the following questions to the best of your ability.

Name:

Veterinarian:

Phone:

DOG

Pet’s Name

Breed

Age

Sex

S/N

Age when altered:

MEDICAL

Are your dog’s vaccinations up to date?

 Yes  No

Does your dog have any medical conditions?

 Yes  No

If yes, explain

Has the dog been diagnosed with and/or treated for any of the following: (Check all that apply)

 Upper respiratory infection  Allergies

Heart murmur

 Tumors

 Epilepsy or seizures

 Organ failure

 Urinary tract infection

 Thyroid disease

 Diabetes

 Other

Is your dog currently given any medications?

 Yes  No

If yes, what medications?

HOME

Please list the people, including yourself, living in your household. Please include ages of children:

Age

Hours away from home

Relationship

Please list all animals in the household:

Name

Species

Breed

Sex

Age

Age now

Sequence

Relationship

obtained

History

Why did you decide to acquire a dog?

Companion

For child

Protection

How old was your dog when you acquired it?

Where did you get your dog? Shelter Newspaper/internet

Friend

Found/Stray

Other

Has the dog had previous owners? If yes, explain (Why given up):

Do you use a crate? If yes, when did you begin to crate your dog?

Does the dog have accidents in the home? __no __yes

How often?______x/week _____x/month or Infrequent

How long is the dog left alone daily?

PLAY

What sort of play does your dog enjoy most? Ball play

Chase games

Tug

Other

None

Dog Owner Surrender Form

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