Surrender A Dog

Dog's Name *

Breed *

Age *

Weight

Color

Sex *

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 Info

Please provide the following information regarding each veterinarian who has seen the Dog.

Veterinarian 1

Veterinarian Name/Practice *

Veterinarian Address *

Address Line 1

City

State

Zip Code

Phone *

Veterinarian 2

Veterinarian Name/Practice

Veterinarian Address

Address Line 1

City

State

Zip Code

Phone

Veterinarian 3

Veterinarian Name/Practice

Veterinarian Address

Address Line 1

City

State

Zip Code

Phone

Please initial here to authorize us to contact the veterinarian(s) listed above and obtain information about the Dog and the Dog's care: *

Has the Dog ever lived with other animals? *

Yes
No

If yes, what other animals? *

Has the Dog had any conflicts with any of these other animals? *

Yes
No

If 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? *

Yes
No
I don't know

Please explain:

Has the Dog ever had any conflicts with children? *

Yes
No
I don't know

If yes, describe each of the conflicts that the Dog has had with children: *

Is the Dog good with other dogs? *

Yes
No
I don't know

Please explain:

Is the Dog good with cats? *

Yes
No
I don't know

Please 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?

Other, Please describe:

Do you leave the Dog outside unattended?

Yes
No

Do you confine the Dog to your property?

Yes
No

If yes, how do you confine the Dog to your property?

Fence
Kennel
Chain or tie-out
Invisible fence

Please 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?

Yes
No

Did the Dog ever escape your property?

Yes
No

If yes, how many times?

How did the Dog escape your property?

Has the Dog received any obedience training? *

Yes
No

If 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? *

Yes
No

If 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? *

Yes
No

If yes, is the Dog overly protective of or overly reactive to any of the following? (check all that apply) *

If 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? *

Yes
No

If yes, describe each of the incident(s) when the Dog snapped at someone: *

Has the Dog ever bitten anyone? *

Yes
No

If 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?

Yes
No

If yes, what problem did it cause?

Is the Dog spayed or neutered? *

Yes
No

Are the Dog's vaccinations up to date? *

Yes
No

If no, when was the Dog last vaccinated and what vaccinations did he or she receive?

Has the Dog had any health problems? *

Yes
No

If yes, what problems has the Dog had? *

Are those problems resolved? *

Yes
No

If no, what health problems does the Dog still have? *

Is the Dog on any medications? *

Yes
No

If 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 diet

Yes
No

If 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 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Signature Date *

Signature (I agree to sign this document electronically) (use mouse to sign) *

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Veterinarian Info

Veterinarian 1

Veterinarian 2

Veterinarian 3

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