Dog Surrender Application

Owner's Information

Full Name *

Email Address: *

Address *

City *

Phone Number *

Dog's Name *

I certify that I am the sole legal owner of this animal and have the right to surrender this animal to Pets Alive Niagara upon approval of this application. *

Yes

No

If no, please do not complete this form.

General Information

Sex *

Male

Female

Spayed/Neutered *

Yes

No

Unknown

Breed *

Age *

Is this known or approximation of age? *

Weight *

Microchipped *

Yes

No

Unknown

If Yes, please provide the number:

History

Why are you surrendering this dog? *

How long have you owned this dog? *

Where did you acquire this dog? *

Has your dog ever bitten/nipped or attempted to bite a person or animal? *

If Yes, under what circumstances and when?

Medical History

RELEASE OF VETERINARY RECORDS

I hereby authorize the veterinarian named herein to release information about me or my pet(s) to Pets Alive Niagara for the purposes of evaluation this application. *

Agree

Disagree

Please, call your veterinarian and give verbal permission to disclose all information that we require to Pets Alive Niagara.

Clinic Name *

Address *

Name of veterinarian *

Phone Number *

Has this dog seen a veterinarian at least once a year? *

Yes

No

Unknown

Has this dog been tested annually for heartworm or tick-borne diseases? *

Yes

No

Unknown

Is the dog currently up-to-date on vaccines? *

Yes

No

Unknown

Date of last vaccination

Has this dog ever been diagnosed with and/or treated for any medical problems including dental issues? *

Yes

No

Unknown

If yes, please explain:

Has this dog ever undergone surgery? *

Yes

No

Unknown

If yes, please explain:

Is your dog currently on any medications/preventatives? *

Is your dog eating a prescription diet? *

Please rate your dog’s teeth out of 5, with 1 being “needs dental work” and 5 being “in perfect shape.” *

1

2

3

4

5

Personality

How would you describe your dog’s personality most of the time? Check all that apply. *

Does the dog display any of the following behaviours?

Jumping up on people

Counter surfing

Resource guarding (i.e., displaying behaviours like growling, snapping, etc. intended to convince other dogs or humans to stay away from a particular “resource,” such as food, treats, toys, a bed or favourite chair, or a person). If so, please explain below.

Protective tendencies towards their owner(s)

Destructive chewing

Mouthing. If so, please explain to what extent below.

Excessive barking. If so, please explain in what situations below.

Separation anxiety

Prey drive (e.g., chases squirrels in yard)

Please, use this field for any further explanations required above.

What is the dog’s energy level out of 10, with 1 being “low” and 10 being “high?” *

Lifestyle & Home Life

Where does your dog spend most of its time? *

Indoors

Outdoors

Both

How does your dog interact with other dogs? *

How does your dog interact with cats? *

Has the dog regularly been around children? *

Yes

No

Unknown

If yes, indicate what age(s):

How did the dog and the children interact?

Have your dog’s experiences with child(ren) always been positive? *

Yes

No

Unknown

If no, please explain:

Is the dog most comfortable with: *

Women

Men

Kids

Teenagers

Seniors

Loves all people

Please tell us some things that your dog dislikes ((e.g., loud noises, being touched in certain places, being groomed, being confined, walking on a leash, strangers approaching the house, etc.). *

Are there any quirks or habits you are not fond of in your dog? (Answering this question helps provide us with valuable insight into your pet and can help us ensure your pet has a successful adoption. Many quirks or habits are common behaviours natural to all dogs and/or have simple solutions that we can share with a future adoptive family.)

Dietary Habits

Which does your dog eat? *

Dry only

Canned only

Both dry and canned

People's food

How often is your dog fed? *

Once a day

Twice a day

Free fed

Training

Is your dog housetrained? *

Yes

No

Occasional accidents

Pee-pad trained

Has your dog received any obedience training? *

Yes

No

If yes, from whom and what methods were used?

What are the basic commands that your dog knows?

Sit

Stay

Down

Come

Heel

Drop it

Other commands

What walking equipment works best with your dog (e.g., flat collar, head halter, front-clip control harness, pressure harness, limited slip collar, prong collar, choke chain, electric collar)? *

Has this dog been trained to wear a muzzle? *

Yes

No

Unknown

Does this dog require a muzzle when at the vet or groomer? *

Yes

No

Unknown

Is your dog used to being in a fenced yard? *

Yes

No

Unknown

Has this dog been crate trained? *

Yes

No

Unknown

How is this dog in the car? *

Is there anything else that you would like us to know about your dog? *

Please include recent photos of the dog

Upload File

Browse...

Upload File

Browse...

Upload File

Browse...

Signature of applicant: *

Date of application: *

Spam Blocker