Surrender A DogPlease enable JavaScript in your browser to complete this form.Dog's Name *Breed *Age *WeightColorSex *The information requested below must be filled in completely and accurately.Why are you giving up this Dog (hereinafter referred to as “the Dog”)? *How long has the Dog lived with you? *In how many other homes has the Dog lived? *From where did you get the Dog? *Veterinarian InfoPlease provide the following information regarding each veterinarian who has seen the Dog.Veterinarian 1Veterinarian Name/Practice *Veterinarian Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Veterinarian 2Veterinarian Name/PracticeVeterinarian AddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneVeterinarian 3Veterinarian Name/PracticeVeterinarian AddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhonePlease initial here to authorize us to contact the veterinarian(s) listed above and obtain information about the Dog and the Dog's care: *Clear SignatureHas the Dog ever lived with other animals? *YesNoIf yes, what other animals? *Has the Dog had any conflicts with any of these other animals? *YesNoIf yes, describe each of the conflicts that the Dog has had with these other animals: *List the ages of the children, if any, in your household: *Is the Dog good with children? *YesNoI don't knowPlease explain:Has the Dog ever had any conflicts with children? *YesNoI don't knowIf yes, describe each of the conflicts that the Dog has had with children: *Is the Dog good with other dogs? *YesNoI don't knowPlease explain:Is the Dog good with cats? *YesNoI don't knowPlease explain:How many hours a day is the Dog left alone? *Describe how the Dog reacts to being alone: *Where does the Dog spend most of his/her time?Always outsideMostly outsideAlways insideIn/out at willIn the garageIn a crateOther, Please describe:Do you leave the Dog outside unattended?YesNoDo you confine the Dog to your property?YesNoIf yes, how do you confine the Dog to your property?FenceKennelChain or tie-outInvisible fencePlease describe selection(s)Fence: What type of fence? How high is it? Kennel: What type of kennel? How big is the kennel? Is the Kennel fully enclosed? Chain or tie out: How long is chain or tie out? Where is it located?If you don’t confine the Dog to your property, is the Dog free-roaming? YesNoDid the Dog ever escape your property?YesNoIf yes, how many times?How did the Dog escape your property?Has the Dog received any obedience training? *YesNoIf yes, what type of obedience training has the Dog received? *Have you ever consulted a trainer or behaviorist regarding any issue(s) concerning the Dog? *YesNoIf yes, describe the issue(s) that were addressed and the results: *What form of discipline/correction have you used with the Dog? *How did the Dog react to that discipline/correction? *Is the dog overly protective or overly reactive? *YesNoIf yes, is the Dog overly protective of or overly reactive to any of the following? (check all that apply) *FoodFamily membersToysCarsProperty Other pets/animalsOtherIf you chose other, please describe? *When the Dog is overly protective or overly reactive, what behavior does he/she exhibit? *Has the Dog ever snapped at anyone? *YesNoIf yes, describe each of the incident(s) when the Dog snapped at someone: *Has the Dog ever bitten anyone? *YesNoIf yes, describe each of the incident(s) when the Dog bit someone: *What types of situations cause the Dog to bark?Has this ever created a problem?YesNoIf yes, what problem did it cause?Is the Dog spayed or neutered? *YesNoAre the Dog's vaccinations up to date? *YesNoIf no, when was the Dog last vaccinated and what vaccinations did he or she receive?Has the Dog had any health problems? *YesNoIf yes, what problems has the Dog had? *Are those problems resolved? *YesNoIf no, what health problems does the Dog still have? *Is the Dog on any medications? *YesNoIf yes, please list the medications: *What type of flea control do you use for the Dog?When is the date of the Dog’s last dose?What type of heartworm control do you use for the Dog? When is the date of the Dog’s last dose?Is the Dog on a special dietYesNoIf yes, what kind of diet and why?Describe the Dog’s idea of a perfect day:Please email us a photo of the Dog at ilovepets@theanimalhavenct.org and provide the name of Dog in the text of your email. I hereby certify the truth and accuracy of all the information that I have provided above. I also hereby certify that I have the legal right to surrender the Dog to The Animal Haven, Inc. (“The Animal Haven”) and that no one else has any right to or interest in the Dog. If The Animal Haven agrees to take in the Dog (which The Animal Haven may or may not do in its sole discretion), I surrender to The Animal Haven all my rights to and interest in the Dog. I understand that if The Animal Haven takes in the Dog, The Animal Haven will try to find the Dog a new home and that I will have no input whatsoever regarding any new home or potential new home found for the Dog. I also understand that if, in the opinion of The Animal Haven, the Dog exhibits any behaviors or has any characteristics that will make it difficult for The Animal Haven to adopt out the Dog to a new home, The Animal Haven may notify me and request that I take the Dog back. If I am so notified by The Animal Haven, I will come to the shelter, pick up the Dog, and take the Dog back home with me.Name *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Signature Date *Signature (I agree to sign this document electronically) (use mouse to sign) *Clear SignatureSubmit