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Surrender
Please complete all required fields!
Current Owner
Date
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Owner’s Name
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Address
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City
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State
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Zip
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Home Phone
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Work Phone
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Dog Information
Dog’s Name
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Sex
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Male
Female
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Age
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Color
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Black/Tan
Red
Fawn
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Albino
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Ears
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Natural
Cropped
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Tail
*
Natural
Docked
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Spayed/Neutered?
*
Yes
No
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Does the dog have any markings?
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Length of ownership
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Where was the Doberman acquired?
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What type of food does the dog eat?
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How often is the dog fed?
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Provide a picture of the dog:
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Additional picture of dog
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Medical History
Date of last visit to the vet:
*
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Select a valid date. If unknown, select today.
Is the dog currently on heartworm prevention?
*
Yes
No
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What Heartworm Prevention Brand do you use?
*
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Which day of the month do you give the heartworm prevention?
*
1st
2nd
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3st
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Results of Last Heartworm Test:
*
Positive
Negative
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Date of last Rabies Vaccination
*
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Date of last DHLPP Vaccine
*
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Date of last Bordetella Vaccination
*
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List any health problems, special needs, or injuries
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Please list any medications and dosages and frequency this dog takes regularly:
Medication Name: Dosage: Frequency: Medication Name: Dosage: Frequency:
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Veterinarian Information
Vet's Name
*
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Vet's Address
*
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Vet's City
*
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Vet's State
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Vet's Zip
*
Enter a number
Vet's Email
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Vet's Phone
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Please use the format xxx-xxx-xxxx
Vet's Fax
Please use the format xxx-xxx-xxxx
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Dog's Behavior
Has the dog ever bitten, snapped, or growled at anyone?
*
Yes
No
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If Yes, please explain:
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This Doberman is (check all that apply)
*
Crate-trained
House-trained
Outside only
Fence Jumper
Inside only
Digger
Walks well on a leash
Counter surfer
Constant barker
Chewer
Likes to swim
Likes strangers
Friendly
Shy
Playful
Aggressive
Fearful
Food aggressive
Toy aggressive
Other
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If other
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This Doberman will chase (check all that apply)
*
Kids
Cars
Bikes
Runners
Inside cats
Outside cats
Birds
Livestock
Balls
Squirrels
Horses
Other
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If other
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Does this dog get along with of the following (check all that apply)
*
Cats
Male Dogs
Female Dogs
Big Dogs
Small Dogs
Birds
Small Animals
Livestock
Horses
Kids
Other
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If other
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Would you recommend this dog be placed with small children?
*
Yes
No
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If no or unsure, please explain:
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Explain any obedience training the dog has had:
*
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Surrender Information
What is the reason for surrender?
*
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Length of time dog can remain in your care until foster space becomes available or dog is placed in permanent home
*
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Additional Information
Please provide any other information to help us place this dog in an appropriate home:
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Donation Amount
Donation Amount
*
$0
$25
$50
$75
$100
$150
$175
$200
$250
$300
$500
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Taking the dog into the HADR program will not only take up valuable foster space that may compromise our ability to save dogs in kill shelters, it will also cost us for basic care and any additional vetting that may be required.
How much can you donate to help find your dog a new home?
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Signature
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I HEREBY RENOUNCE ANY AND ALL CLAIM TO THE DESCRIBED DOG. I FULLY UNDERSTAND THAT I WILL NOT EVER KNOW THE WHEREABOUTS OF THE DOG. WITH THIS INSTRUMENT THE DOG BECOMES THE PROPERTY OF HOUSTON AREA DOBERMAN RESCUE. I AM IN FULL AGREEMENT WITH THESE TERMS OF SURRENDER.
Type your name (virtual signature)
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Date
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