Surrender - Beulah Land Dog Rescue

General Dog Information:

Dog's Name:*

Breed:*

Color / Markings:*

Age:*

Weight:*

Gender*

Male
Female

Altered (spayed/neutered):*

Yes
No

Current on Vaccines:*

Yes
No

Heartworm Preventative given monthly:*

Yes
No

Owners Personal Information

Owner's Name:*

Co-Owner's Name:

Address:*

City*

State:*

Zip:*

Home Phone:*

Cell Phone:*

Email Address:*

Background Information on Dog:

Please describe fully why you want to rehome your Dog.*

Where did you get your Dog?*

How long have you had the Dog?*

If you adopted from someone else, explain why they gave up the Dog to you.

Is this Dog in any physical danger at this time? (Explain)*

What is the maximum time you can continue to keep the Dog?*

What brand and bariety of food do you feed your Dog (i.e. Purina ProPlan)?*

Is this Dog completely housebroken? If has accidents, how often? (Explain)*

Is your Dog kept outside? If so, where?*

Is your dog crate trained?*

Medical History:

Please describe any existing or resolved medical conditions. Please note if this Dog has been used for breeding purposes, had major surgery (other than sterilization), or been diagnosed with any hereditary diseases:

When was this Dog last seen by its Veterinarian (please note reason for visit)?*

Date of most current Rabies vaccination?*

Date of last Distemper Combination vaccination?*

Date of last Bordatella (Kennel Cough) vaccination?*

Date of most current Lymes Disease vaccination?*

Date of most current Heartworm/Lymes test? Results?*

What brand of Heartworm Preventative do you use?*

What brand of Flea Preventative do you use?*

Does your Dog have any health issues? (Explain)*

What medications or supplements is your Dog currently taking? (Explain)*

Veterinarian Information:

Vet Name:*

Address:*

City:*

State:*

Zip:*

Phone:*

Fax:*

Do you give permission for one of our volunteers to contact your vet?*

Yes
No

** Please note a complete medical history needs to be given to Beulah Land Dog Rescue at the time of the Dog surrender **

Temperament:

Has your Dog ever bitten someone or attempted to bite someone? (Explain)*

Does your Dog growl or act aggressively at people or other dogs? (Explain)*

Has your Dog been socialized with small children?*

How is your Dog in the car?*

Does your Dog let you trim its nails?*

Yes
No

Does your Dog let you touch its feet, face and belly?*

Yes
No

Does your Dog have any formal obedience training?*

Yes
No

Does your Dog have any issues sharing its toys with other Dogs or humans? (Explain)*

Does your Dog have any issues with Dogs and humans walking by or being in close proximity when it is eating?*

How active is your dog? (Explain)*

Is your Dog destructive? (Explain)*

How does your Dog walk on a leash?*

Does your Dog have any fears (ex. Lightening, loud noise, being alone)? (Explain)*

Please describe any special likes or dislikes you feel will be beneficial for Beulah Land Dog Rescue to be aware of in placing your pet:*

Living Environment

Where is your Dog kept when you are not home?*

Where does the Dog sleep?*

What other types of Dogs are in your home?*

What are the ages of the people living in the house?*

How do you exercise your Dog (note the amount of time the Dog is exercised each day)?*

Is your yard fenced (please note type of fence)?*

Your Contact Information:

Form completed by:*

Relationship to dog:*

Address:*

Home Number:*

Work Number:

Cell Number:*

Email Address:*

CAPTCHA

Surrender Your Dog To Us

Surrender Questionnaire

General Dog Information:

Owners Personal Information

Background Information on Dog:

Medical History:

Veterinarian Information:

Temperament:

Living Environment

Your Contact Information: