Surrender

Submitting this form is NOT a commitment from VIP Rescue to accept your dog. Information provided will help us decide if the dog can be placed with one of our fosters until adopted into a new home. Please also see the surrender FAQ if you have not done so already.

Owner Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

County(Required)

Phone(Required)

Email(Required)

Dog's Name(Required)

Gender(Required)

Breed(Required)

Date of Birth (approximate if not known)(Required)

Weight (pounds)(Required)

Color(Required)

Microchip #(Required)

Has the dog ever bitten anyone?(Required)

Details of biting incident(s)(Required)

Has the dog had dental treatment(s)?(Required)

Date of last dental (approximate if not known)(Required)

Are vaccines current?(Required)

Date of last Rabies vaccine (approximate if not known)(Required)

Date of last Distemper/Parvo vaccine (approximate if not known)(Required)

Date of last Bordatella vaccine (approximate if not known)(Required)

Other vaccines – type & date

Describe current general health(Required)

Any chronic illnesses?(Required)

Describe chronic conditions(Required)

Is dog currently taking any medications (other than routine preventive e.g. flea and heartworm)?(Required)

Explain medications and conditions treated:(Required)

How long have you had this dog?(Required)

Where did you get the dog exactly? (pet store, breeder, shelter/rescue, etc.)(Required)

Veterinarian Contact Info:

By providing this information I give VIP Rescue permission to call my veterinarian to discuss the health of this dog, treatments medications, and obtain any records available.

Veterinarian Name(Required)

Veterinarian Phone(Required)

Veterinarian Email(Required)

Has dog been bathed and groomed recently? (Pets must be clean and free of parasites to be accepted into our rescue program)(Required)

Heartworm prevention type and date of last dose given:(Required)

Flea prevention type and date of last dose given:(Required)

Date of last heartworm test:

Is the dog housetrained?(Required)

Is the dog good with men?(Required)

Is the dog good with women?(Required)

Is the dog good with children?(Required)

Is the dog good with other dogs?(Required)

Is the dog good with cats?(Required)

Dog's activity level:(Required)

Sleeping habits (dog bed, crate, with people, other):(Required)

Has dog been crated when you leave?(Required)

Can use a doggie door?(Required)

Describe any training dog has received – professional, informal, behaviors/abilities.(Required)

Is the dog accustomed to walking on a leash? (short/long, with or without pulling, etc.)(Required)

Eating schedule:

Brand of food:(Required)

Number of times fed per day:(Required)

Amount per feeding:(Required)

Exercise / play (how often, duration, walking, running, prefers toys, etc.)(Required)

General disposition (calm, defensive/territorial, shy, fearful, separation anxiety, etc.)(Required)

Owner comments / reasons for surrender:

Why are you no longer able to keep this dog as your pet? (changes in employment, housing, family/roommate, conflicts with other pets, unable to control behaviors, etc.)(Required)

Describe what type of home would best suit the dog you are rehoming:(Required)

Please upload a current photo of your pet:(Required)

Max. file size: 32 MB.

Surrender Agreement

I/We transfer all of our rights, title, and interest of the above noted pet(s) to VIP Rescue Inc. VIP Rescue Inc. may take such actions it sees fit with the pet(s) including medical attention necessary and placement into another home. We relinquish all rights, title, and interest as of this date. I/We authorize VIP Rescue Inc.. to obtain any necessary veterinarian records for this dog. I understand that VIP Rescue Inc.is a not-for-profit volunteer organization, and we release it from all liability or responsibility of any kind.

Digital Signature(Required)

Date signed:(Required)

Veterinarian Contact Info:

Eating schedule:

Owner comments / reasons for surrender:

Surrender Agreement

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