Owner Surrender Dog Information & History – Doberman Rescue of Atlanta

Release Information

Person's Name*

Address*

Cell Phone

Home Phone

Email*

Dog's Name*

Birth Date or Age*

Gender*

Male
Female

Breed*

Veterinarian

Veterinarian Phone #

Veterinarian Address

How long have you owned this dog?*

Why are you surrendering this dog?*

Medical Information

Do you know when this dog was last vaccinated?*

Yes
No

Date of Last Vaccinations*

Do you know when this dog last had heartworm prevention?*

Yes
No

Date of Last Heartworm Prevention*

Has this dog been spayed or neutered?*

Yes
No
Not sure

Date of Spay/Neuter (if known)

Does this dog have any medical conditions or illnesses you are aware of?*

Yes
No

Describe Medical Conditions or Illnesses*

Dog Information

Color*

Ears*

Cropped
Not Cropped (natural)
Not Sure

Tail*

Tail docked
Tail not docked (natural)
Not sure

Is this dog comfortable with...*

Select All
Male Dogs
Female Dogs
Cats
Children
Men
Women
Strangers
Riding in the Car

Only check boxes if you know that the dog does not have issues with the selection.

Which children have you seen the dog interact with?*

Additional information

Feel free to provide any additional information regarding dog's interactions or experiences with anything checked above.

Is this dog housebroken?*

Yes
No
Not sure

Is this dog crate trained?*

Yes
No
Not sure

Is this dog leash trained?*

Yes
No
Not sure

Does this dog...*

Jump fences
Dig
Chew
Guard Food
Guard Toys
None of the above

Additional information

Feel free to provide any additional information regarding dog's behavior.

Does this dog bark...*

Has this dog ever bitten a human?*

Yes
No
Unknown

Explain bite history*

Have you ever received any citations from any governmental entity or been sued because of this dog?*

Yes
No

Explain government citation or lawsuit*

Has this dog ever attacked another dog, or gotten into a fight with another dog?*

Yes
No
Unknown

Explain dog fight or attack*

Does this dog have separation anxiety?*

Yes
No
Unknown

How does separation anxiety manifest itself?

Does the dog howl, bark, destroy things, destroy crate...

Does this dog allow you to take away bones, toys, food?*

Yes
No
Unknown

What does the dog do when you try to take things from it?*

Does this dog try to keep other dogs or people away from his/her owner?*

Yes
No
Unknown

Does this dog know any commands?*

Yes
No
Unknown

Which commands does the dog know?*

Please give any additional information you have on the dog's temperament.

Owner Surrender Form Accuracy*

By checking this box, I certify that all of the information I have given in this form is true and complete.

Today's Date*