EmailMe Form - SURRENDER QUESTIONNAIRE

Surrendering Owner's Name *

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone *

### - ### - ####

Email *

Dog's Name *

Dog's Date of Birth or age *

What is the dog's weight and approximate height? *

What color is the dog? *

Is the dog: *

spayed/neutered

still intact

What vet care is the dog due for: *

Please describe any special health needs (seizures, luxated patella, hypothyroid, diabetes, needs daily medication etc). *

Has the dog ever broken their leg? *

Yes

No

Please provide contact information for your dog's current veterinarian.

Include Clinic name, phone number, and owner's name under whom the dog can be located. *

When was the dog last vaccinated for Rabies?

When was the dog last vaccinated for Distemper/Parvo?

When was the dog's last heartworm preventative given?

How often does the dog get teeth brushed, and do they tolerate it?

How often does the dog get nails trimmed, and do they tolerate it?

What food does the dog eat?

What behavioral or training issues does the dog have? *

Where does the dog stay during the day or when no one is home? *

Where does the dog stay at night? *

Can the dog stay in a crate, remain quiet, and keep the crate clean? *

Please describe the dog's housetraining skills. *

Does this dog potty while on a leash? *

Is this dog a flight risk; have they ever attempted to flee the home, jump the fence, or otherwise escape? *

Yes

No

Describe how the dog gets along with other dogs and cats. *

Describe how the dog does with meeting new people and being in new situations. *

Describe how the dog gets along with children. *

Does the dog seem especially fearful of a certain person/group of people?

If so, please specify.

Does your dog know any commands? If so, please describe.

Please use this section to provide more information or describe any health or behavioral issues listed above.

What do you like best about this dog? What are their best qualities?

Why do you want to surrender this dog to rescue? *

If there is an URGENT NEED FOR IMMEDIATE SURRENDER, please describe the situation.

Is there anything else we need to know about this dog?

We do NOT deny dogs based on age, health, or behavioral issues.

Please sign below to give permission for us to contact your dog's current veterinarian to transfer records.

You will be contacted when a foster home becomes available. Feel free to follow up or check in at any time, but keep in mind that IGCA Rescue of MN/ND is staffed entirely with unpaid volunteers, so please be both patient and persistent.

Thank you for protecting your dog by choosing to surrender to rescue.

Surrendering Owner 1 Signature *

Surrendering Owner 2 Signature

Date Submitted *

MM / DD / YYYY