Surrender Questionnaire

Owner's Contact Information *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Spayed/Neutered *

Yes

No

Vaccinated *

Yes

No

Has the dog been de-wormed? *

Yes

No

Phone Number of Veterinarian *

(###)

###

####

Has this dog ever been to a groomer? *

Yes

No

Has this dog ever acted aggressively towards or bitten: *

A person

Another dog

A cat

Livestock Animals

None of the above

Has this dog lived with other dogs or other animals in the same household?

Yes

No

Has this dog had any incidents of urinating/defecating inside of the home?

Yes

No

How would you rate this dog’s recall?

Good

Average

Poor

Has this dog been fed table scraps or any kind of human food?

Yes

No

Has this dog been known to take food off of a counter top or got into the garbage?

Yes

No

Has this dog been known to eat unusual items other than food?

Yes

No

Has this dog been known to chew items other than their own toys? (ie. furniture, footwear etc)

Yes

No

Has this dog been known to bark excessively?

Yes

No

Has this dog ever taken any obedience classes?

Yes

No

DISCLOSURE *

I have disclosed all pertinent information and answered all questions regarding this dog truthfully and to the best of my knowledge. I understand that I can be held liable if I have knowingly falsified or purposely failed to disclose any past behaviors that could result in serious injury to another person or animal.