Dog Surrender Form

Your Information

First Name*

Last Name*

E-mail Address*

Street Address*

Street Address (cont'd)

City*

State*

Zip Code*

Home Phone*

Work Phone

Other Phone

The Dog's Information

Name of Dog

Sex of Dog

Male

Female

Date of birth (or estimation of age)

Color

Weight of dog (if estimating,please be as accurate as possible)

Is the dog spayed or neutered?

Yes

No

Temperament info

Please be honest in your answers to the following questions

Is the dog accustomed to and used to children? Please explain

Is the dog accustomed to and used to other animals? Please explain

Please describe the dog's overall temperament

Has the dog ever bitten anyone?

Yes

No

Has the dog ever attempted to bite anyone?

Yes

No

Has the dog ever shown aggression, violent, or inappropriate behavior?

Yes

No

If you answered "Yes" to any of the above questions, please use this space to describe the circumstances:

Veterinary Info

Veterinarian Name

Veterinarian Address

Veterinarian City, State, Zip

Veterinarian Telephone Number

Are the dog's vaccinations current?

Yes

No

Date of last vaccinations, if known

Has the dog been on heartworm preventative?

Yes

No

About The Surrender

Please describe all pertinent details of how the dog came to the attention of the NeoRescue Inc. (for instance, where the dog was found, why the dog is being surrendered/ how the dog was found, etc.)

Please describe the physical condition of the dog. (For instance, general health, coat condition, general fitness, etc.)

Are there any conditions that may need veterinarian treatment. If so, give description (i.e. cherry eye, mange, etc.)

Is this dog adoptable in your opinion? Explain why.

Is there any other information that you can provide that will help rescue find the right home for this dog?

Please type your name here. By doing so, you apply your signature to this form and affirm that all information above is true and correct to the best of your knowledge