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Surrender

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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Cell Phone
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Email
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Dog Information

Dog’s Name*
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Sex*
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Age*
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Color*
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Ears*
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Tail*
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Spayed/Neutered?*
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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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Is the dog currently on heartworm prevention?*
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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?*
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Results of Last Heartworm Test:*
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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:
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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*
Please use the format xxx-xxx-xxxx

Vet's Fax
Please use the format xxx-xxx-xxxx

 

Dog's Behavior

Has the dog ever bitten, snapped, or growled at anyone?*
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If Yes, please explain:
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This Doberman is (check all that apply)*
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If other
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This Doberman will chase (check all that apply)*
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If other
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Does this dog get along with of the following (check all that apply)*
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If other
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Would you recommend this dog be placed with small children?*
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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*
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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?

 

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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*
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