Dog Surrender

Your Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone number(s) *

Name of Dog *

Are you the dog's legal owner? *

Yes
No

If you are not the legal owner, what is your connection to the dog? *

Where did you get your dog from? *

Please provide the name of the humane society or rescue group *

If Other, please provide further information *

Reason for surrender *

The dog's breed *

Dog's gender *

Male, not neutered
Female, not spayed
Male, neutered
Female, spayed

The dog's age *

Dog's weight (or approx. weight) *

How long have you had the dog? *

Is your dog current (up-to-date) on the rabies vaccine *

Yes
No
I don't know

Is your dog current (up-to-date) on the parvovirus and distemper vaccine? *

Yes
No
I don't know

Is your dog microchipped? *

Yes
No
I don't know

Can you provide health records for the dog? *

Yes
No
I don't know

Does your dog have any ongoing medical conditions or requirements? If yes, please explain. *

Name of veterinarian and/or clinic *

Phone number of veterinary clinic *

Is your dog fully house trained? *

Yes
No

Is your dog pee pad trained? *

Yes
No

Is your dog crate trained? *

Yes
No

At home, is your dog always kept: *

Indoors
Outdoors

Where is your dog kept when no one is home? *

Where does your dog sleep at night? *

Is your dog vocal when left alone? *

Yes
No

Is your dog destructive when left alone? *

Yes
No

Is your dog good in the car? *

Yes
No
I don't know

Is your dog fearful of being groomed/touched? *

Yes
No
I don't know

Can you clip your dog’s nails? *

Yes
No
I don't know

Is your dog ok with you administering ear or eye drops? *

Yes
No
I don't know

Is your dog good with cats? *

Yes
No
I don't know

Is the dog currently living with a cat? *

Yes
No

Is your dog good with other dogs? *

Yes
No
I don't know

Is the dog currently living with another dog? *

Yes
No

Does your dog currently frequent off-leash dog parks? *

Yes
No

Is your dog good with children? *

Yes
No
I don't know

Is the dog currently living with children? *

Yes
No

What ages are the children? *

Is your dog fearful of strangers? *

Yes
No
I don't know

Does your dog jump fences? *

Yes
No
I don't know

Does your dog walk well on leash? *

Yes
No
I don't know

Does your dog pull and lunge when walking on leash? *

Yes
No
I don't know

Is your dog friendly with new people/strangers? *

Yes
No
I don't know

Has your dog had any obedience classes? *

Yes
No

Has your dog ever bitten a human? *

Yes
No

Has your dog ever bitten another dog? *

Yes
No

Does your dog protect/guard toys, food, treats or other items? *

Yes
No

How does your dog react to dogs when on a walk? *

Doesn't care/barely notices them
Friendly and pulls to see other dog
Barks and/or lunges
Calmly approaches to sniff

Can your dog go up and down the stairs? *

Yes
No
Yes, but not easily

How often does your dog go for walks and for how long each time? *

What commands does your dog know (e.g. sit, down, come)? *

How many times per day does your dog get fed? *

Once
Twice
Three times
Has food in bowl all the time

What food is your dog currently eating? *

Any other information you would like to share about your dog? (For example personality, past experiences, etc.) *

What type of home and lifestyle would best suit your dog? *

File Upload - photo 1

Click or drag a file to this area to upload.

Please upload a photo of the dog

File Upload - photo 2

Click or drag a file to this area to upload.

Please upload a second photo of the dog, different from the first

File Upload - photo 3

Click or drag a file to this area to upload.

We would prefer a third photo, if possible

Are you willing/able to make a donation to our organization? (not mandatory) *

Yes
No

How did you hear about our rescue?

If other, please indicate how your heard about us

Please note that our online forms are currently not functioning properly. While we are working to fix them, if you are wanting to surrender your dog, please email us at speakingofdogs@gmail.com.