First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone*

Alt Email

Text/Pager Email

What is your dog's name?*

What breed is your dog? If you don't know, please say "unknown mix"*

Is your dog male or female?*
Choose one: Male - intact Female - intact Male - neutered Female - spayed

What color is your dog?*

What type of coat does your dog have?*
Choose one: Short coat (standard GSD) Plush coat Long coat

How old is your dog? (approximately)*

How old was your dog when you got him/her?*

Where did you get your dog?*
Choose one: Friend Pet Shop Breeder Received as a gift Found stray Animal shelter/Humane Society Abandoned Other (please elaborate in comments box)

If you got your dog from a rescue, breeder, pet store, shelter or humane society, please tell us which one, what city and state they're in, and (if known) how to contact them

Why do you want to surrender this dog? BE COMPLETELY HONEST.*

What is the last possible date you can house your dog?*

What's the name of your vet clinic?*

Your vet's address, with city and state: *

Your vet's phone number, with area code: *

Is your dog spayed / neutered?*
Choose one: Yes No

If your dog was spayed/neutered by a different vet than listed above, who did the surgery? Give name, address, and phone.

Is your dog microchipped or tattoed?

Date of last Rabies vaccination:*

Date of last distemper/parvo vaccine:*

Date of last bordatella (kennel cough) vaccine:*

List any other vaccines your dog has had and the date given

Date of last hearworm test:*

Is your dog on any medications? If so, list the meds, what they're for, and dosages. Include any medications your dog has been on in the last year and what they were for.

Does your dog have any special needs? These include mental conditions such as extreme shyness or neuroses, serious under-socialization, extremely high drive/energy, medical conditions, disabilities, or particular medical problem s/he has been treated for (allergies, dermatitis, food or medication sensitivities, etc.)*

Is your dog a working dog or from working lines?
Choose all that apply: Yes No Don't Know Acts like it (has very high drive - high ball drive, strong prey drive, in constant motion, needs at least an hour of heavy exercise every single day, if not exercised heavily every single day becomes "wired")

Where does your dog mostly live? *
Choose one: Inside Only Outside Only Inside and Outside

Is your dog house trained?*
Choose one: Yes No

Can your dog be trusted to stay alone and loose inside the house for periods of time?*
Choose one: Yes No

If yes, what's the longest period your dog can be left alone?*

If your dog can't be left alone & loose in the house, why not?*

Does the animal jump fences or dig to escape a yard:*
Choose one: Yes No

Has your dog ever been kept on a chain or tether?*
Choose one: Yes No

Where does your dog sleep?*

Is your dog crate trained?*
Choose one: Yes No

When and where is your dog usually fed?*

What brand/type of food does your dog eat and how much?*

Does your dog have any behaviors or tendencies that could cause problems if they live with other dogs? IF SO, WHAT ARE THEY? [examples = pushy over food, jealous of affection, possessive of bedding or toys, rough play, don't want other dogs in their face or space, high energy, etc] *

Is the animal afraid of any of the following?

How would you describe your animal:

How else would you describe your dog?*

What commands does your dog know? In what language? *

How does your dog react to being touched / handled / groomed? Any sensitivities or reactions? At ease, tense, any no-go zones, etc?*

Does your dog prefer..:*
Choose one: Men Women Does not have a preference

How does your dog react to strangers? BE SPECIFIC. GIVE DETAILS.*

How does your dog react to someone ringing the door bell or knocking at the door?*

How is your dog with other dogs?
Choose all that apply: Gets along with all other dogs Good with large dogs Good with small dogs Good with males Good with females Good with mellow dogs Good with those who play nicely Good with those who play rough Dominant, pushy Alpha, will not tolerate anything other than a submissive dog Dog aggressive, cannot be around other dogs

Describe your dog's behavior with other dogs in detail. BE SPECIFIC. GIVE EXAMPLES. Is s/he ok with only certain types of dogs (for example, males/females, small dogs, large dogs, mellow dogs, energetic/rough dogs, etc). Has your dog ever gone after another dog? What happened?*

Does your dog have ANY aggressions? (people, dog, cat, toy, treat, food, territory, owner protectionism, etc)
Choose all that apply: Yes No

If "YES" to aggressions, DESCRIBE IN DETAIL. BE SPECIFIC. Exactly what behavior does your dog display and under what conditions? There's a big difference between straining on a leash at another dog, and wildly lunging while baring teeth and growling. With food aggression, there's a big difference between alerting, growling, stiffening, baring teeth, etc. *

Has your dog ever bitten anyone? (CLEARLY DISTINGUISH BETWEEN A SCRATCH, A NIP AND AN ACTUAL BITE). What were the exact circumstances? How serious was the bite (required medical attention and if so how much/what kind, etc)*

Describe anything else about your dog's personality / behavior / traits not covered by previous questions.*

Comments: Please tell us anything else that will help us better understand you, your circumstances, your lifestyle, your approach to training a dog, the dog's place in your family, etc. *