Pawsitive Results
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Surrender your pet
Please fill out this form to the best of your knowledge. Providing we are able to assist you, your answers will help us get to know your pet and give us background information to enable us to place him/her in a home that best matches his/her personality and needs. Please provide us with as much information as possible and feel free to elaborate.
Owner's Information
Name
(Required)
First
Last
Telephone
(Required)
Email
Street Address
(Required)
Street Name
City
State / Province / Region
ZIP / Postal Code
Pets' Information – General
Pets' Name
(Required)
Breed
(Required)
Mixed
Mixed
Aged
(Required)
Gender
(Required)
Male
Female
Status
Spayed/Neutered
Unaltered
How long have you had this dog?
(Required)
Where did you get this dog?
(Required)
Why are you surrendering this dog?
(Required)
Is this dog Microchipped?
(Required)
Yes
No
Number
(Required)
Where does this dog primarily live (inside, outside, both)? Please explain:
(Required)
Pets' Information – Medical
Has this dog ever bitten a person?
(Required)
Yes
No
Please explain
(Required)
Has this dog bitten anyone in the last 10 days?
(Required)
Yes
No
Has this dog bitten another animal?
(Required)
Yes
No
Please Describe:
(Required)
Please explain
(Required)
Does this dog have/had any known medical issues/conditions?
(Required)
Yes
No
Please include any required medications:
(Required)
What Veterinary Clinic do you use?
Veterinarian Phone Number
Most Recent Vaccinations
Rabies
MM slash DD slash YYYY
DAPP
MM slash DD slash YYYY
Bordetella
MM slash DD slash YYYY
Other
MM slash DD slash YYYY
Is your dog heartworm negative?
Yes
No
When was your dog last tested for heartworm?
Can you verify when your dog was last tested for heartworn?
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.
Date of last heartworm test
MM slash DD slash YYYY
Heartworm Preventative Used
Date Last Heartworm Prevention Given
MM slash DD slash YYYY
Flea/Tick Preventative Used
Date Last Flea/Tick Prevention Given
MM slash DD slash YYYY
Dog Information – Behavioral
Does this dog have any of the following behavioral issues? Check all that apply. Please explain each issue (Please be honest, as it lets us know what we may need to work on and will aid in helping us place him/her in the right home).
Separation or other Anxiety
Chewing
Excessive Barking
Digging
Inappropriate Urinating
Begging
Chasing cars, animals, people, etc.
Protective of house, family, food, toys, etc
Aggression toward people, other animals, etc
Fear of loud noises/objects
Fear of men, women, children (ages), groomer, vet, etc
My dog has none of these issues
How does this dog behave around cats (if unknown, please state “unknown”):
(Required)
How does this dog behave around other dogs (if unknown, please state “unknown”):
(Required)
How does this dog behave around children (if unknown, please state “unknown”):
(Required)
How does this dog behave around strangers (if unknown, please state “unknown”):
(Required)
Dog Information – Training
Is this dog House Trained?
(Required)
Yes
No
Crate Trained?
(Required)
Yes
No
Has this dog been boarded in the past?
(Required)
Yes
No
If yes, how did he/she do at the kennel?
(Required)
Has this dog had formal obedience training?
(Required)
Yes
No
Does this dog know any commands?
(Required)
Yes
No
If yes, list commands
Can this dog be trusted to be alone for extended periods of time?
(Required)
Yes
No
If No
Hidden
Is there any other information you’d like to provide about your pet?
(Required)
Yes
No
Is there any other information you’d like to provide about your pet?
(Required)
Please describe
I have completed this form to the best of my knowledge. I authorize Match K-9 Rescue and Rehab Inc. to obtain copies of medical records from my Veterinarian.
Owner Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.
Training
Registration Form
In Home Training
Group Classes
Testimonials
Testimonials – Greenville
Palm Beach
Our Trainer
About Nancy
Philosophy
Puppy Protection
About
Get Ready!
Breed All About It!
Foster Friends
Happy Tails
Forms
Adoption Application
Foster Application
Surrender your pet
Pawsitive Info
Doggie Demos
Health
Natural Remedies