First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Home Phone*

Cell Phone

Is your dog up-to-date on rabies vaccination?*

Is your dog up-to-date on DHLPP vaccination?*

Is your dog up-to-date on Bordetella vaccination?*

Does your dog receive heartworm preventatives? *

Does your dog receive flea and tick control? *

Veterinarian/Practice Name:

Veterinarian's Phone:

Dog #1 Name:

Is your dog male or female?*

Is your dog spayed or neutered?*

Please provide your dog's birth date. If you cannot provide that, please tell us the age of your dog.*

How much does your dog weigh?*

What breed is your dog?

Where did you get your dog?

When did you get your dog?

Is your dog good with others? Please select all that apply:

Has your dog ever injured another person? If so, please describe the circumstances:*

Has your dog ever injured another animal? If yes, please describe.*

Does your dog have any injuries or illnesses? Please describe.*

Please describe your dog’s personality and traits. Select all that apply:

Why are you surrendering your dog? *

Anything additional we should know about your dog?

I have read and answered each question on this Owner Surrender Form and have provided truthful answers. I am providing consent to SSR to contact my Veterinarian for further information if needed. Submission of this form provides a signature. *