First Name: Last Name: Street Address City Phone Number Email Address Dog's Name Registration or Microchip Number Breed Weight Age Where did you get the dog from Please indicate your reason for surrendering the dog to Pomeranian and Small Breed Rescue Current, or most recent veterinarian and clinic Veterinarian's Address Whose name is the dog listed under at the clinic? (e.g. your name, your maiden name, spouse's name, etc) Date of Last Checkup Is the dog spayed or neutered? Yes No Unknown Please select all vaccinations/prevention programs that the dog is currently up to date on:Rabies vaccination DHPP vaccination Bordetella (kennel cough) vaccination Monthly heartworm prevention program Monthly flea prevention program None
Does the dog currently have or has he/she ever had any of the following:A spinal injury or episode A urinary tract infection Mites, fleas or ticks A weak bladder or bowel Kennel cough Ringworm If you selected any of the options in the previous question or the dog has any other medical conditions, please explain How would you describe the dog's interaction with people? How would you describe the dog's interaction with other dogs? Is the dog housetrained? Yes No
On an average day, how many hours does the dog spend alone? When you are away from home, where does the dog stay? In a crate Runs free in the house Confined to a room or specific area Outside Doggy Day Care Someone else's home Other How does the dog respond to bathing/grooming? Likes Dislikes Unknown How does the dog respond to nail clipping? Likes Dislikes Unknown How does the dog respond to being petted or stroked? Likes Dislikes Unknown How does the dog respond to being picked up or held? Likes Dislikes Unknown
Is the any additional information that you would like us to know about the dog? Please list any items transferred with the dog
Terms & Conditions
I am the owner(s) of this animal and hereby relinquish all present and future rights and claims to this animal and possessions transferred with it to Pomeranian and Small Breed Rescue. I understand that once I relinquish the animal, the animal will not be available to be returned to me. I certify that I have fully informed Pomeranian and Small Breed Rescue of all known or suspected medical or behavioural issues or concerns with the animal. Further, I have communicated all known information necessary to ensure the animal's continued happiness and welfare. To the best of my knowledge, this dog has no behavioural or medical issues that would cause it to be an unsuitable family pet. I understand that I will not be provided with information about the animal's whereabouts. Sending this form constitutes an electronic signature and agreement to the stated above.
