Online Owner Surrender Form

Surrendering Owners Information

Date *

Owners Name *

Owners Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Owners Phone Number *

Owners Email Address *

Owners Drivers License Number and Expiration

Dogs Information

Dogs Name *

Approximate Date of Birth

Dogs Approximate Age *Approximate age in weeks, months, or years.

Breed *

Alterations

Cropped EarsDocked TailDew Claws RemovedDog Spayed / Neutered

Dogs License Number

Color *

Black and RustRed and RustBlueFawnAlbino / WhiteOther

Describe color *

Is the dog microchipped? *

YesNo

Microchip Number

How long have you had the dog? *

If you found the dog as a stray, what have you done to find the owner?

Why are you surrendering this dog? *

Please provide as much detail and be as open as possible.

Was the dog acquired from a breeder? *

YesNo

Do you have a signed contract with this breeder that requires you to return the dog if you can no longer care for him or her? *

YesNo

Do you affirm that you have contacted the breeder and asked them to take this dog back, and that the breeder declined to do so? *

YesNo

Is the dog AKC registered? *

YesNo

Is the registration being surrendered with the dog? *

YesNo

Is the pedigree being surrendered with the dog? *

YesNo

Veterinarian Information

Are the dogs medical records available? *

Please contact your vet at the time of completing this form and ask that they send full records to contact@azdoberescue.org and also have them add a note to your file giving us approval for discussing/accessing the records. This will make it easier for us to take your dog.YesNo

Practice Name *

Veteranarian's Name *

Veteranarian's Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Veteranaraian's Phone Number

May we request the dog’s veterinarian to release the dog’s medical records to us? *

YesNo

Onwers initials and date *Please type your initials and date to authorize our request for records.

Vaccination History

Notice Vaccination history is extremely important, as over-vaccinating dogs is highly dangerous. We will vaccinate again if we do not have a vaccination history.

Date of last rabies vaccination

Rabies vaccination duration

1 year3 yearUnknown

Date of last Distemper/parvo/combo vaccine given

Type of distemper/parvo vaccine

DH2PPDH2PPL

Date of last Bordatella vaccine

Date of last Heartworm test

Heartworm test result

Date of last heartworm preventative given

Date of last fecal worm check

Worm results

Disease, Injury, Surgery Information

Has this dog ever been diagnosed or treated for Valley Fever? *

YesNoUnknown

Is this dog von Willebrand’s affected? *

YesNoUnknown

Has this dog ever been diagnosed or treated for tick fever? *

YesNoUnknown

Has this dog ever been diagnosed or treated for Wobblers? *

YesNoUnknown

Has this dog ever been diagnosed or treated for dilated cardiomyopathy? *

YesNoUnknown

Besides those noted above, list all other medical conditions (allergies, diseases, wounds, breaks, abnormalities, illnesses, surgeries, pregnancies, and indicate all current concerns.

Dogs Observed Behavior and Temperament

Instructions Your answers will help determine where we place this dog. To give him or her the best chance of a great forever home, please answer honestly and completely. For any of the following questions, use the comment box as needed. Please tell us about any temperament or behavior issues or concerns we should be aware of.

Dog accepts / gets along well with

Please check all boxes where you have personally observed the dog interacting with or getting along with the item/person/animal in the list. Only check boxes where the dog was comfortable and not displaying fear or hesitation around the item/person/animal described.Large male dogsSmall male dogsLarge female dogsSmall female dogsCatsMen (adult male)Women (adult female)Young children (0 - 10 years of age)Older children (10 - 18 years of age)

Dog accepts / gets along well with (cont.)

Please provide as much context as possible, especially around unchecked boxes (from previous question).

Dogs social performance

Please check all boxes where you have personally observed the dog interacting in the social situation listed. Only check boxes where the dog was comfortable and not displaying fear or hesitation in the situation described.Large crowds (5 or more persons)Small crowds (2 - 4 persons)Car ridesVeterinarians officePresence of large animals (horses, etc)

Training

Please check boxes where the dog has already been trained (or has received formal training if relevant).HousebrokenCrate trainedObedience trainedProtection trainedAgility trainedSchutzhund trainedRally trainedConfirmation trained

Describe the dog

Describe the dogs behavior, personality, and mannerisms in your own words with as much detail as possible.

Describe the ideal home for this dog and why.

Has the dog ever

Please check boxes where the dog has either attempted or successfully performed any of the behaviors listed.Escaped the yardReturned when calledJumped or climbed fence/wallEaten inappropriate or inedible objectsChewed inappropriate or inedible objectsBarked excessivelyMarked inside home

Has the dog ever bitten

To the best of your knowledge, check any box where the dog has bitten or attempted to bite the animal/person described in the list.CatAnother dogAdult maleAdult femaleAdolescent maleAdolescent femaleMale childFemale childSkater or bicyclist

Please describe any incident(s) of bite(s) *

Please be as open and descriptive as possible.

List any other behaviors / concerns

Please describe any other behaviors or areas of concern with regard to the dog. Please be as open and descriptive as possible.

DHDR Owner Surrender Form

Surrender Questionnaire

Surrendering Owners Information

Dogs Information

Veterinarian Information

Vaccination History

Disease, Injury, Surgery Information

Dogs Observed Behavior and Temperament

Verification

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