Surrender Form

We understand that sometimes circumstances change. Please complete this form as thoroughly as possible â€" accurate information helps us find the best home for your dog. All fields are required unless otherwise noted.

About You

Full Name *

Best Time to Contact

MorningAfternoonEveningAnytime

Home Address *

City *

State

Zip Code *

Email Address *

Cell Phone

Home Phone

Work Phone

Dog 1

Name *

Breed

Color / Markings

Weight (approximate)

Surrendering more than one dog?

No Yes - 2 dogs Yes - 3 or more

Dog 2

Name

Breed

Color / Markings

Weight (approximate)

Additional Dogs

List additional dogs (Name / Breed / Age / Gender / Spayed-Neutered / Color / Weight)

Dog History & Background

Is the dog microchipped?

Yes No Unknown

Microchip Number(s)

Is the dog currently licensed?

YesNo

Food (brand, amount, how often)

Exercise per day

Where does the dog sleep?

Has the dog received any obedience training?

Yes No

What training and commands does the dog know?

Behavior & Temperament

Has the dog ever bitten or snapped at a person or animal?

Yes No

Please describe the incident(s) in detail:

Behavioral issues (check all that apply):

Excessive barking Destructive chewing Jumping on people Pulling on leash Separation anxiety Resource guarding Fear/anxiety Escaping yard/house None

Veterinary Information

Veterinarian Name / Practice

Vet Phone

Vet Address

Vet City

Up to date on vaccinations?

YesNoUnknown

Date of last heartworm test

On heartworm prevention?

YesNo

Any current medical conditions?

Yes No

Please describe current medical conditions:

Any known allergies?

Yes No

Please describe known allergies:

Any medications? If yes, please list:

Reason for Surrender

Please describe your reason in more detail: *

Have you tried any solutions to keep the dog?

Yes No

What solutions have you tried?

Have you tried to find a home for the dog yourself?

YesNo

Any preferences for the new home?

Is there anything else we should know about your dog?

Acknowledgment

I confirm the information provided is accurate to the best of my knowledge. I understand that Michigan Standard Poodle Rescue will make every effort to place my dog in a loving home, but cannot guarantee placement. *