Dog Owner Surrender
Animal's Name
Gender
Male
Female
Description of animal
Breed guess
Age
How long have you had the animal?
Has the animal been spayed/neutered?
Yes
No
Unknown
Does the dog have a microchip? If yes, please put the microchip number.
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Where did you get the animal from initially?
Owner's reason for parting with animal
How does the animal act around children?
Does the animal dislike either men or women?
How would you describe your animal's behavior? For example: bold, shy, timid, aggressive, affectionate
How does your animal react to grooming?
How does your animal behave at the vets?
Does your animal have any medical conditions that are undergoing treatment?
Has your animal had any previous operations or treatment for medical conditions?
Does your animal have any known allergies?
Has he/she ever bitten anyone? If yes, please put when and describe the situation.
Do you have vaccination records for the animal?
No
Yes
Is your dog current on the following? Check all that apply.
DHLPP
Bordetella
Rabies
Heartworm Prevention
Flea/Tick Prevention
Has the animal ever been destructive in the house? Please describe
Is the animal good with dogs? Please specify behavior and large/small/any size.
Is the animal good with cats? Please specify behavior.
Is the dog housetrained?
Does the animal travel well?
Do you leave the animal alone for any period of time? If so, how long for and do you have concerns about them being on their own?
Is the dog walked on a collar or a harness?
How does the dog react to other dogs outside of the home, e.g. on walks?
Does the animal guard bones or toys from people or other animals?
Please upload one clear, well-lit picture of the animal.
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Person providing information
Owner
Owner's representative
Owner's name
Owner or representative's phone number
Owner or representative's email
I hereby certify that I am the rightful owner/keeper/caretaker/custodian of the animal(s) who is/are the subject of this Animal Surrender Form, hereinafter referred to as “the animal.” I hereby surrender any and all property rights of the animal. I release and discharge Charming Pet Rescue from any and all claims, obligations, liabilities, and causes of action whatsoever arising out of or relating to the ownership, possession, or disposition of the animal(s) and agree to hold harmless Charming Pet Rescue from and against any and all such rights claims, obligations, liabilities and causes of action which may be asserted by other parties. I certify that no other person has a right of property to the animal. I also hereby certify that the animal has not bitten or scratched a human or another animal within the past 10 days. I understand that once I relinquish the animal, the animal will not be available to be returned. I further certify that I have read and understand these terms.
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No
Yes
Please type your full name as agreement to the Animal Surrender terms if Charming Pet Rescue agrees to take in your animal.
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Please choose today's date as the day you agree to these terms.
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