Dog Intake Surrender Form

Name*

Age*

Sex*

Male
Female

Description

Spayed/Neutered*

Yes
No
Not sure

Microchip*

Yes
No
Not sure

Breed

Where did you acquire dog?

Pet store
Breeder
Private Party
Shelter

If Breeder, name and address/phone of breeder

Name and phone of veterinarian

Date of Last Vaccines

DHLPP

Bordatella

Corona

Rabies

Any health issues? If yes, please describe

Behavior and preferences

What brand of food do you feed?

How often do you feed?

What time(s)?

How much?

Where does the pet sleep?

Where is pet kept during the day?

What commands does dog know?

How is pet with strangers?

Has the dog ever growled at or bitten anyone? Please explain

Does your pet.....

Like to ride in cars?

Yes
No

Like to swim?

Yes
No

Dig?

Yes
No

Jump fences?

Yes
No

Like toys?

Yes
No

Let you take toys or food away?

Yes
No

Urinate when scared?

Yes
No

Come when called?

Yes
No

Come when called?

Yes
No

Growl at strangers?

Yes
No

Chase cars?

Yes
No

Is your pet.....

Afraid of storms?

Yes
No

Used to children?

Yes
No

Good with children?

Yes
No

Good with cats?

Yes
No

Good with dogs?

Yes
No

Used to being groomed?

Yes
No

Housetrained?

Yes
No

Crate trained?

Yes
No

Obedience trained?

Yes
No

Likes and dislikes?

Positive and negative traits?

Any other information that would be helpful for placement or for new owners?

Why are you giving this pet up?

TO BE COMPLETED BY THE RELINQUISHING OWNERS: We certify that we own the above dog and that this dog has not shown any signs of aggression, or bitten anyone in the past ten (10) days and that the statements above are true and accurate. We agree to indemnify and hold harmless Fuzzy Pawz Rescue by, from and against all claims, suits, damages, liabilities and costs related to or in any manner connected with this dog. We further acknowledge understanding that the dog becomes the property of Fuzzy Pawz Rescue, and that they may place the dog, spay/neuter, or euthanize it as they see fit or as necessary. (If above dog should unprovoked, attack or bite someone while in our care, we would have no alternative but to euthanize.) This form also authorizes Fuzzy Pawz Rescue to acquire any and all veterinary records from the veterinarian listed above.

Name

First Last

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone

Dog Intake Release Form

Date of Last Vaccines

Behavior and preferences

Does your pet.....

Is your pet.....

Featured Dog

Featured Cat