Surrender or Help Survey
Are you wanting help or to surrender you dog
Name of Dog:
Breed:
Gender:
Age:
Spayed or Neutered:
Weight:
Name of Veterinarian:
Phone:
Hospital/Clinic:
City/Town:
State:
Zip:
Color(s)/Markings of dog:
Scars,tattoos, or injuries:
Dog Microchipped? If so, provide number get along with
Does the dog get along with other dogs?
Does the dog get along with cats?
Does the dog get along with small children?
Medical Information: **(OWNER TO PROVIDE ALL MEDICAL RECORDS W/ DOG.)
On heartworm preventative:
If yes, type?
Date of last rabies vaccine:
Due next?:
Date of last DHLPP:
Date of last Bordetella:
Type and brand(s) of dog food:
Amount/how often fed:
Behavioral Issues:
If Yes please fill out the problems
Your name and phone number or e-mail (when surrendering this space will be your electronic signature)