Owner Surrender Request

Anchor Paws Rescue Owner Surrender Request

Please fill out the form below and our Owner Surrender Coordinator will be in contact with you within 48 hours to review the options we can offer you during this difficult time. Please be honest when completing this form, as this information will be used to help ensure that we find the right home for your dog. We take pride in caring for the dogs entrusted to us and strive to make your dog feel safe in their new environment. The answers you provide to us will help ensure that we make the right foster home match.

Contact Information

First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
-

Email*

Home Phone*

Cell Phone

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Dog's Info

Why do you need to rehome your dog at this time?*

How quickly do you need the dog removed from your residence?*

What is the pet's name that you are surrendering?*

How did you acquire this dog?*

How old is the dog?*

What breed is this dog?*

What is the sex of the dog?*

Male	Female
No preference

Has this dog been Spayed/Neutered?*

Yes

How much does the dog weigh?*

When was the last time this dog was seen by a vet?*

What is the name, address and phone number of the vet that last saw this dog?*

What vaccinations has this dog had? Select all that apply.

Rabies	Distemper Combo (aka, "5-in-1")
Bordetella	Leptospirosis
Other	None of the Above

Is this dog currently on heartworm prevention?

Yes	No
Unknown

If dog is currently on heartworm preventative, what is the brand used and when is the last time the dog was given?

What type/brand of food does the dog currently eat? How much per serving and how many servings/day.*

Does the dog have any medical concerns we need to be aware of? Please check all that apply.

Body lumps	Cancer
Cannot control bladder/bowels	Cataracts/Impaired Vision
Deafness	Dental disease/missing teeth/chronic bad breath
Diabetes	Diarrhea
Food/seasonal allergies	Hair Loss
Heart murmur/heart disease	Hip/joint problems
Other infections	Other parasites
Underweight	Walks with a limp
Worms	Other
None of the above

Please detail any other health issues we need to be aware of.

What is the overall temperament of your dog? Check all that apply.

Aggressive	Energetic
Fearful	Friendly
Lap dog	Lazy
Nervous	Playful

Does your dog have any other behavioral issues we need to be aware of? Please check all that apply.

Aggressive with children - too much for small children	Aggressive with only dogs of the same sex
Aggressive with other dogs	Aggressive with people
Excessive barking	Fearful of new situations
Food aggression	Marking in the house
Resource guarding (toys, food, even humans)	None of the above

Does this dog have a documented bite history? If YES, please describe the incident here:

Does the dog get along with other dogs?*

Does the dog get along with cats and/or other small animals

Has this dog lived with children? What ages?

Is the dog housebroken?

Yes

Is the dog crate trained?*

Yes

Does the dog walk well on a leash?*

Would you consider caring for the dog while we post the dog for adoption on our website?*

Yes	No
I may need assistance from time to time

What other options are you considering for rehoming your dog? Are you in contact with other rescues? If so, please list them.

Is there anything else you would like us to know about this dog? Again, being as honest as possible will help us determine our ability to help you and place the dog in the right environment if we are able to.*

By submitting this application, I affirm that ALL information is true and complete. I agree to give permission for a representative of Anchor Paws to call the veterinary practices I have listed. I also understand that a home visit and assessment of the dog by an Anchor Paws representative may required. I also agree that I (We) are the legal owners of this dog and are taking this action of our own free will and are willing to sign an irrevocable owner surrender form.

I agree

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