Surrender Form - Bluegrass Doberman Rescue

Surrender

Owner's Name:*
First Last
Phone:*
Email:*
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Dog's Name:*
Breed:
Sex:*
- Male
- Female
Altered?*
- Neutered
- Spayed
- Unaltered
Color:
Approximate Weight:
Cropped ears?
- Yes
- No
Docked Tail?
- Yes
- No
Age or birth date:
Length of ownership:
Why is the animal being given up?*
Veterinarian Clinic's Name:
First Last
Veterinarian Clinic's Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Veterinarian Clinic's Phone:
On heartworm preventative?*
- Yes
- No
Heartworm preventative brand:
Monthly due date:
Up to date on rabies shot?*
- Yes
- No
If yes, county/state/tag number:
Additional vaccines given and dates:
Does your dog have allergies?
- Yes
- No
If so, to what?
Is your dog on any medication(s)?
- Yes
- No
If so, which medication(s)? What condition is being treated & how regularly does it occur:
Does your dog have any old injuries or health concerns?
- Yes
- No
If yes, please explain:
Has this dog bitten you or anyone else?*
- Yes
- No
If animal has bitten, please explain:
Where was this animal acquired?
- Shelter
- Breeder
- Rescue
- Pet Shop
- Friend/Relative
- Newspaper
- Found/Stray
- Born at home
If from a breeder, please provide name and city of breeder:
Have you contacted the breeder to see if they want to take their dog back?
- Yes
- No
Describe the dogs living area (house, outdoor pen, etc.):
Number of hours dog was: kept inside, kept outside, left unsupervised?
Where was the dog kept when home alone?
- Crate
- Run of the House
- One specific room
- Garage
- Outside
Where did dog sleep?
- Owner's Bed
- Owner's Bedroom
- Dog Bed
- Couch
- Crate
- Garage
- Outside
Indicate those who lived with this dog:
- Women
- Men
- Seniors
- Older children (10+ yrs old)
- Younger Children (< 10 yrs old)
- Male Dogs
- Female Dogs
- Large Dogs
- Small Dogs
- Cats
If other pets lived in the same home with this dog, list dogs/cats and gender/age:
How did the dog get along with the other animals in your household? Were there times you kept the animals separated? Who was the dominant animal was the dominant animal in the home?
Does your dog have any issues with men/women/children? Please explain.
If no, please list the ages you would recommend for this dog:
If a child goes near the dog when it is eating or takes away a toy/bone/etc, would the child be in danger? Please explain.
Describe your household:
- Active
- Sedentary
- Noisy
- Quiet
- Average
Types of training:
- None
- Puppy class
- Obedience class(es)
- Home training
- Agility
- Protection
Dog knows how to:
- Sit
- Stay
- Come/Recall
- Lie down
- Heel
- Walk nicely on leash
- Ride quietly in car
- Fetch
Dog is frightened of:
- Thunder
- Fireworks
- Vacuums
- Sirens
- Appliances
- Trucks
- Water
- Hands
- Feet
- Boots
Is there anything that makes this dog show signs of aggression towards people? Please explain.
Is your dog house broken?
- Yes
- No
Is your dog crate trained?
- Yes
- No
How often is the dog let out or walked?
How does the dog tell you?
Accidents occur?
- One a day
- Once a week
- Once a month
- Only when dog is left alone
- Rarely
- Never
Are the accidents:
- Urination
- Defecation
Where have accidents occurred?
How have you dealt with the problem?
- Paper/pad trained
- Crated
- Checked with vet for medical problem
- Only allowed dog in certain areas
- Kept outside
- Diapered
- Just dealt with it
When outside, the dog is:
- In a fenced yard
- In a dog run
- Walked on leash
- Loose
- Tied Out
- On skyline cable
Outside behavior includes:
- Digging
- Barking at outside interests
- Barking to come in
- Chewing plants
- Visiting neighbors
- Using small pool
- Running fence line
- Jumping at fence
- Jumping over fence
- Digging under fence
If loose, dog will:
- Run away
- Stay in yard
- Stay in yard only if owner present
- Wander over to the neighbors
- Pester neighborhood animals
- Get into the garbage
- Come home on its own
Dog will chase:
- People
- Vehicles
- Bicycles
- Cats
- Livestock
- Birds
- Wildlife
- Ball
- Frisbee
Animals this dog does not get along with:
Has the dog ever killed another animal such as a rabbit or cat?
- Yes
- No
When leashed this dog:
- Aggressively lunges at other dogs
- Playfully lunges at other dogs
- Lunges at people
- Lunges at kids
- Is overprotective
- Behaves nicely
- Enjoys being petted
- Pulls too hard
- Is frightened
Would you suggest this dog be placed with other big dogs?
- Yes
- Maybe/Selective
- No
Would you suggest this dog be placed with other small dogs?
- Yes
- Maybe/Selective
- No
When is the dog fed?
- Twice a day (AM & PM)
- Once a day (AM)
- Once a day (PM)
- Food available at all times
Dog is fed:
- Dry food only
- Canned food only
- Mixture dry/canned
- Semi-moist
- Raw
- Table scraps
List brands of food & amount fed:
Any special treats?
Dog’s favorite toys & play activities:
- Fetch
- Frisbee
- Hide & seek
- Rawhides
- Natural bone
- Nylabones
- Cow hooves
- Pig ears
- Chewing sticks
- Stuffed toys
Any bad habits the new owner should be aware of? (i.e. stealing food off the counter/table, raiding the garbage, etc.)
What has been done to correct the problem?
Is dog allowed on the bed, furniture, etc.?
Which traits best describe this dog:
- Playful
- Rambunctious
- Affectionate
- Vocal
- Lazy
- Destructive
- Aloof
- Dominant
- Shy
- Needs to be only pet
- Needs to be only dog
- Needs to have company all the time
The dog is accustomed to:
- Bathing
- Nail trimming
- Ear cleaning
- Teeth brushing
- Medicating
- Brushing
- Professional grooming
- Car travel
- Air travel
- Dog shows
Electronic Signature*
- I accept
- I decline
As owner, or custodian acting in good faith, I give the above-described animal irrevocably to Bluegrass Doberman Rescue (BDR) or whatever disposition BDR deems best. My signature waives any and all further rights of ownership to this animal. I understand that Bluegrass Doberman Rescue (BDR) has NO further obligation to inform me of this animal’s final disposition or furnish me with any information on the new adoptive home of this animal. To my knowledge, no one has been bitten by this animal. To my knowledge, the above answers are true and correct. None of the answers to the above questions will necessarily exclude any dog from being taken into our program. BDR volunteers allow dogs to be “fostered” in their private homes, which often include other dogs, both big and small, cats, other pets, children, etc. Being as truthful as possible enables us to place the dog in an appropriate foster home without endangering our volunteers. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.