First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Cell Phone*

Dog's Name:*

Breed (or best guess):*

Age or Date of Birth (approximate if unknown): *

Sex:*
Choose one: Female Male

Spayed/Neutered:*
Choose one: Yes No Unknown

Weight (approximate):*

Color/Markings:*

Is this dog current with its rabies vaccination?*
Choose one: Yes No Unknown

Is this dog current with its DHPP vaccination?*
Choose one: Yes No Unknown

When is the last time this dog has been seen by a veterinarian?*

Veterinarian Name & Phone: *

Reason for Surrender - Please explain why you are surrendering this dog (be as honest and detailed as possible — this helps us place them successfully):*

Where did you acquire the dog?
Choose all that apply: Breeder Other Rescue Shelter

What is your relationship to this dog?*

How long have you owned this dog?*

Please list any known medical conditions, injuries, allergies, or special needs:

Is the dog currently on medication? (Please list):

How would you describe your dog’s personality? (ie: Friendly/Shy/Nervous/Energetic/Calm/Protective)*

Has your dog ever bitten or attempted to bite a person or another animal? Please explain. How many times and under what circumstances?*

Any known fears or triggers?*

How does your dog get along with other dogs?*
Choose one: Great Selective Aggressive Not Tested

How does your dog get along with children? *
Choose one: Great Okay Nervous Aggressive Not Tested

How does your dog do with cats?
Choose one: Great Chases Aggressive Not Tested

Is it necessary to place this dog as an only dog?

House Trained?*
Choose one: Yes Mostly Uses Pee Pads No

Crate Trained?*
Choose one: Yes No Unknown

Leash Trained?*
Choose one: Yes Pulls Fearful

Knows basic commands (check all that apply):
Choose all that apply: Sit Stay Come Down Crate None

Can it be left alone? If yes, for how long?*

What type of home do you think would be best for this dog?*

Is there anything else we should know to help this dog succeed?

A RECENT picture of your dog is needed before we can accept him/her into rescue. Please e-mail a picture immediately after submitting this form to info@pixiemamasrescue.com . Until we receive a recent picture of your dog, your request cannot be processed. Yes, I will send a picture. Initial and date*

Is this dog safe for the time being?*
Choose one: Yes No Unknown

By checking YES, I acknowledge that Pixie Mamas Rescue is a New York State–registered 501(c)(3) nonprofit, foster-based animal rescue organization. I hereby permanently and irrevocably surrender and transfer all legal ownership, custody, and control of the dog listed in this form to Pixie Mamas Rescue if the surrender is accepted. I affirm that I am the lawful owner of this dog and that the dog is not stolen, subject to any lien, seizure, quarantine, bite hold, or involved in any pending legal action. I further affirm that, to the best of my knowledge, the dog has not bitten any person within the last ten (10) days and has not been exposed to rabies. I understand and agree that if surrender is accepted, Pixie Mamas Rescue has sole discretion regarding the dog’s care, foster placement, medical treatment, behavioral training, transfer to another rescue, adoption, or humane euthanasia if deemed medically or behaviorally necessary. *
Choose one: Yes No Unknown