Dog Surrender Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (Home or Cell) *

(###)

###

####

Gender *

Male

Female

Size *

Small (5-20lbs)

Medium (21-40lbs)

Large (41+ lbs)

Is it spayed or neutered? *

Yes

No

Is it up to date on its rabies vaccine? *

Yes

No

When was the date of its last rabies vaccine?

MM

DD

YYYY

Is it up to date on its distemper vaccine? *

Yes

No

When was the date of its last distemper vaccine?

MM

DD

YYYY

Has it been tested for heartworms? *

Yes

No

Is it on monthly heartworm prevention? *

Yes

No

When was the date of its last heartworm prevention dose given?

MM

DD

YYYY

Does the dog get along with other dogs? *

Yes

Sometimes

No

Not Sure

Does the dog get along with cats? *

Yes

Sometimes

No

Not Sure

Does the dog get along with children? *

Yes

Sometimes

No

Not Sure

Can you foster the dog while it's up for adoption? *

Yes

No

Is the dog housebroken? *

Yes

No

If you adopted your dog from a rescue, have you contacted the rescue first to inquire about surrendering the dog?

Most rescues have policies in place that require the adopted pet be returned to them.

Yes

No

I affirm the above questions were answered truthfully and that I am the legal owner of this dog. *

I agree

I disagree

I agree that I will email a photo of the dog within 24 hours to heartlandsmallanimalrescue@gmail.com with the subject of "(Dog's name) - (Your name) - Surrender" *

I agree

I disagree

Please help us care for your dog while we work to rehome *

Suggested donation for a dog surrender is $50. However, any amount is helpful.

I agree

I cannot donate at this time