First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone

Please provide your dog's name.*

Please provide your dog's age.*

Please provide your dog's gender.

Please provide your dog's weight.*

Please provide your dog's breed specification:

Other- specifically:

Please select the reason for rehoming your dog.*
Choose one: Deployment Divorce Financial Medical - Dog Medical - Owner Too Energetic

Please select your dog's likes. This helps to match your dog with the right caregiver.

Please select your dog's dislikes.

Please indicate if your dog has ever injured a person or animal.

If your dog has caused injury to an animal or person , please describe the nature of the injury [bite, nip, scratch, knocked down, or hurt] and the circumstances. {Example: kids were playing, dog intervened, person was taking a toy away,etc.}

If your dog injured an animal or person was Animal Control contacted? Or medical attention required for the injured person or pet?*
Choose one: Yes No

If yes, please explain the outcome from Animal Control and/or the medical visit. [If No, please enter N/A.]*

Please tell us where your dog spends his/her time.

Does your dog guard toys, food, people?*
Choose one: Yes No

If yes, describe the behavior - does the dog growl, freeze, bark, lunge or try to bite? [If No, please enter N/A.]*

Please select the vaccinations your dog has had in the last 12 months.

Please indicated if your dog has been Spayed/Neutered.

Please provide information on any medical condition/illness.*

Please select any behavior issues contributing to the need to rehome your dog? {This helps ensure we have the right resources to help.]

Please, tell us where you dog came from: breeder, pet store, etc. Also, please let us know if there is a 'must surrender' by date.*

If your dog has had training, please describe: *

Please, list all veterinarians, including mobile clinics, Name, Address(es) and Phone Number(s), that have provided care for your previous [in the last 3 years] and current pet[s]. By providing this information, you are authorizing a veterinary reference check by a VGSR representative.*

I/We have read and carefully answered each question on this Intake-Surrender Form and have provided truthful answers. I/We understand that VGSR will rely on the answers I/we have provided in going forward with the Intake process.  I/We are providing consent to VGSR to contact the VET provided on the Intake-Surrender form for further information on the dog indicated.

(Submitting this form provides a signature):