Surrender Form - Colorado Pug Rescue

Date*

Name*

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Email*

Primary Phone*

Alternate Phone

Name of dog:

Age*

Birthdate

Sex:*

Male
Female

This dog is:*

Spayed
Neutered
Intact
Don't Know

Breed:

Color:

Fawn
Black

Why are you surrendering this dog?

How long have you owned this dog?

Where did you obtain this dog?*

Housetraining:

Housebroken (accidents are rare)
Mostly housebroken (occasional accidents)
Not housebroken (frequently has accidents in the house)

Where is the dog kept during the day?

Outdoor kennel
Fenced yard
Crate indoors
Basement
Garage
Tied up outside
Loose indoors
Indoors with access to a dog door

Where is the dog kept during the night?

Outdoor kennel
Fenced yard
Crate indoors
Basement
Garage
Tied up outside
Loose indoors
Indoors with access to a dog door

Where is the dog kept when no one is home?

Outdoor kennel
Fenced yard
Crate indoors
Basement
Garage
Tied up outside
Loose indoors
Indoors with access to a dog door

The dog has lived in the same household with:

Cats
Dogs
Caged birds
Kids 0-10
Kids 11-adults

Other:

Please describe your dog's behavior and habits (check all that apply):

Other:

Has your dog ever growled at you or anyone else?

Yes
No

If yes, please explain:

Has this dog ever bitten or snapped at you or anyone else?

Yes
No

If yes, please explain:

Has this dog bitten or broken the skin on anyone in the past 10 days?

Yes
No

If yes, please enter the date it occurred:

Has your dog ever fought with another dog?

Yes
No

If yes, please describe the situation:

Were there food, toys, or rawhides involved?

Yes
No

Is your dog microchipped?*

Yes
No

What is the microchip number?

This dog is given heartworm preventative medication:

Year round (every month)
Part of the year (every 6 months)
Never

This dog knows:

Sit
Down
Stay
Shake
Roll over

Other:

The dog's diet is (select all that apply):

Canned
Dry
Table scraps

Brand(s) of dog food?

What are the dog's favorite toys?

What (approximately) is the date of the last vaccinations?

Veterinary Clinic name:*

Clinic Phone:*

Please list any illnesses or injuries that the new guardian of this dog should be aware of:

Is there anything else we should know about this dog?