NHS Dog Surrender Form
Sign in to Google to save your progress. Learn more
Your first and last name: *
Your phone number, including area code: *
Your address (include city, state, and zip code): *
Your county of residence: *
Your email: *
Please indicate the reason(s) for surrender: *
We may have alternatives to help keep your pet in your home OR provide you with information to find him/her a new home without having to enter the shelter. Would any of the following resources help you to keep your pet in the home? Check all that apply: *
Required
Dog's name: *
Dog's age (specify in years, months, and/or weeks): *
Dog's breed and colors *
Dog's gender *
Is your dog spayed or neutered? *
Is your dog microchipped? *
Where did you get your dog? *
How long have you had your dog? (Please specify in years, months, etc.) *
Including yours, how many homes has your dog had? *
Has your dog bitten a human, breaking skin within the last 10 days? *
How many times has your dog bitten an adult? *
How many times has your dog bitten a child? *
How many of these bites have broken skin to cause bleeding? Enter N/A if not applicable. *
When did the last bite occur?
MM
/
DD
/
YYYY
Please describe the incident(s), in detail, or enter N/A if not applicable. (age of victim, body part bitten, severity of bite, what started the bite behavior, did the bite break skin)? *
Does your dog give any warning signs that he/she is going to bite? *
If yes, what are the warning signs (freezing, showing teeth, growling, barking, etc.)? Enter N/A if not applicable. *
Have there been any changes to the household, including the environment, health, or routine of the people or pets since the biting started? *
Including yourself, which of the following age groups live in your house?
Check all rows that apply to your household
0-3 years
4-6 years
7-12 years
13-17 years
18-29 years
30-59 years
60+ years
Do children that don’t live with you visit your home frequently? *
How would you describe your dog with children? *
Required
In your opinion, what age(s) of children would live safely and happily with this dog? *
Required
What other animals has your dog lived with? *
Required
Does your dog get along with other pets in the home *
If no, is this dog the resident dog or the newest addition? Enter N/A if not applicable. *
Describe any issues your dog has had with other dogs (guarding resources, playing too rough, etc.) *
What kind of housing has your dog lived in? *
Required
Where is your dog generally kept? (Check all that apply) *
Required
How long is your dog left alone during the day? *
How does your dog react to being left alone? *
If your dog displays destructive behavior, please describe what items they destroy. Enter N/A if not applicable. *
How does your dog react to being in a crate or kennel? *
If crated, how long does your dog spend in the crate on an average day?
Clear selection
Is your dog house trained? *
Does your dog do any of the following while playing? *
Required
Is your dog afraid of anything? If yes, please specify: *
Does your dog display fearful or anxious behaviors in response to any of the following scenarios? *
Required
Please describe the fearful or anxious behavior in the above scenarios. *
How does your dog react to the following? (check all that apply) *
No reaction
Never tried
Barks
Shows teeth
Growls
Snaps
Bites
People touching/taking food, bones, toys, other items
Other pets touching/taking food, bones, toys, other items
Familiar people approaching owner/family
Unfamiliar people approaching owner/family
Familiar people entering home/yard
Unfamiliar people entering home/yard
Restraining/hugging
Grooming/brushing
Clipping nails/handling paws
Pulling/grabbing collar
Scolding/punishing
Excessive/rough petting
Does your dog become aggressive towards other dogs? *
If yes, what behaviors does your dog exhibit when he/she is being aggressive? *
Required
What types of dogs cause your dog to become aggressive *
Required
In what situations does your dog become aggressive to other dogs?   *
Required
Does your dog stop the aggressive behavior if you call him/her off and ask for a trained behavior or toss a treat?   *
Has your dog ever started a fight with another dog? *
If yes, how many times and what were the circumstances? If no, enter N/A. *
Did the fight(s) result in injury to either dog?   *
If yes, please explain. Enter N/A if not applicable. *
Have any of the dogs involved required medical attention following the fight? *
If yes, please explain. If no, enter N/A. *
Has the dog ever bit you or another person when being reactive to or fighting with another dog?   *
If yes, please explain. If no, enter N/A. *
Please describe any other behavioral issues your dog has.   *
Please list any major changes in your household recently, including the environment, health, or routine of the people or pets that may have affected your dog’s behavior *
Does your dog have recent or ongoing history of any of the following conditions? (check all that apply) *
Required
Is your dog currently on any medications? *
If yes, please list them:
Please provide any additional information on your pet’s health: *
Has your dog ever been seen by a veterinarian? *
If yes, what is the name of your vet, their practice, phone number and location, and when was the last visit?
Is your dog vaccinated for rabies *
If yes, please indicate the date of the rabies vaccination and the expiration date. Enter N/A if not applicable.
How does your dog do at the vet or groomer? *
Does your dog need to be muzzled during visits to the vet? *
Is there anything else you’d like us to know about your dog? *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms