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Owner Surrender Form
Please fully fill out this form so we can accurately determine how best to help.
Your name
Email
Phone
Select an Address
I hereby relinquish the following animal(s) to the Roxy’s K-9 Rescue:
Breed guess(es):
How old are the pet(s)?
Are the pet(s) male/female and fixed or not?
Male (not fixed)
Male (neutered)
Female (not fixed)
Female (spayed)
Are the pet(s) microchipped?
Are the pets current on vaccinations and preventatives?
DHLPP
Bordetella
Rabies
Heartworm Prevention
Flea/tick prevention
None of the above
Does the pet have any medical issues?
Vet name and phone number
Has this pet bitten anyone in the last 10 days?
Choose an option
Is the dog crate trained?
Choose an option
Can the dog be trusted alone in the home without being crated?
Choose an option
Does the dog have any behavioral issues?
Fear/aggression toward other dogs
Fear/aggresstion toward cats or other animals
Fear/aggression toward strangers
Fear/aggression toward children
Separation or other anxiety
Chewing
Excessive barking
Digging
Not house trained
Food aggression
Chasing/herding
Overprotective
Jumping up
Biting
Fear of loud noises
None of the above
Please explain any of the behavioral issues.
List any commands the dog knows:
Why are you getting rid of the pet(s)?
I agree that typing my name here constitutes an electronic signature.
Today's date
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