Surrender Form

If you have a dog you cannot keep, please fill out our temperment evaluation form to find out if your dog is eligible for our owner surrender program. You can submit it online using the form below, or download and print this form, fill it out and return it to the address listed at the top.
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Your contact information
First Name:
Last Name:
Title: Ms.   Mrs.   Mr.   Dr.
Primary Phone:   Number is:  Home   Cell   Work
Other Phone:   Number is:  Home   Cell   Work
Street Address:
City:   State:     Zip: 
Email Address:
 
Dog Information
Dog's name:    Age:    Sex:Male  Female
Breed:
Medical conditions, if any:
 
Surrender Information
Reason for surrendering this dog:
How long have you had this dog?
Where did you get this dog?
Has this dog ever been abused or neglected?   Yes     No
Do you wish to be contacted when this dog is adopted?   Yes     No
 
Dog Temperment Information

Regarding your dog's experience with other DOGS:

Has your dog lived with other dogs?   Yes  No  Don't know
Does your dog get along with other dogs?   Yes  No  Don't know
Does your dog prefer dogs that are...   Male  Female  Don't know
Is you dog generally...   Dominant  Submissive  Don't know

Regarding your dog's experience with CATS:

Has your dog lived with cat(s)?   Yes  No  Don't know
Does your dog chase cats?   Yes  No  Don't know

Regarding your dog's experience with PEOPLE:

Does your dog have a preference for...   Men  Women  Don't know
Has your dog lived with children?   Yes  No  Don't know

Dog's Medical History

Is your dog altered (spayed/neutered)?   Yes  No
Has your dog been on heartworm preventatives?   Yes  No
Is your dog current on vaccines?  Yes  No
Has your dog been microchipped?  Yes  No  Don't know
Has your dog ever bitten anyone?   Yes  No  Don't know

Dog's Behavioral History

Does your dog dig?   Yes  No
Does your dog bark excessively?   Yes  No
Does your dog chew?   Yes  No
Does your dog jump fences?   Yes  No
Is your dog crate trained?   Yes  No  Don't know
Is your dog housebroken?   Yes  No
Please enter any additional comments about your dog here:

Contact us
Special Pets Rescue
P.O. Box 1247
Lower Lake, CA 95457
Phone: (707) 350-7008 or (707)994-0123

Email: info@specialpetsrescue.org