Owner Surrender Form

Please complete this form as thoroughly as possible. Your honest and candid responses allow us to better help the dog and keep them safe.

Use one Owner Surrender Form per dog.

Please submit any paperwork in your possession related to the dog, such as vet records, temperament testing, and AKC papers, along with this form.

Lend A Helping Paw Shih Tzu Rescue Owner Surrender Form

To turn in a dog to rescue

- Step 1 of 3

Owner Information

Name *

First

Last

Email *

Email

Confirm Email

Phone *

Address *

Address Line 1

Address Line 2

City

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Zip Code

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Dog Information

Name *

Age *

Date of Birth (if known)

Breed *

Approximate weight (lbs) *

Male or Female? *

• Male
• Female

Microchip # (if known)

Color *

Distinguishing marks (if any)

Reason(s) for surrendering the dog *

How long have you had the dog? *

Where did you get the dog? *

If from a Rescue or Animal Shelter, please list the name below. *

Did you sign any adoption or breeder contract that requires you to return the dog to the originating rescue, shelter or breeder, should you no longer be able to care for the dog? *

• Yes
• No

Is the dog good with other dogs? *

• Yes
• No
• Unknown

Is the dog good with cats?

• Yes
• No
• Unknown

Is the dog good with children? *

• Yes
• No
• Unknown

What are the ages of the children who have been around the dog? *

Is the dog housebroken?

• Yes
• No
• Partially
• Unknown

Is the dog Spayed or Neutered? *

• Yes
• No

Is the dog up-to-date on vaccinations? *

• Yes
• No
• Unknown

Is the dog currently taking any heartworm preventative?

• Yes
• No
• Unknown

Does the dog have any medical conditions? *

• Yes
• No
• Unknown

Please list any medical needs or medical services rendered.

Please list any medications the dog is currently taking.

Please provide the name and address of your veterinarian below.

May we contact your veterinarian?

• Yes
• No

Is the dog possessive of and/or protective toward any of the following? Select all that apply.

• Owner or family members
• Their body
• Food - to people
• Food - to other pets
• Toys - to people
• Toys - to other pets
• Other

If "Other" was selected above, please elaborate below. *

Has the dog ever snapped at or bitten people? *

• Yes
• No

If "Yes" was selected above, please elaborate below (when, how, why). *

How does the dog react to strangers?

Has the dog been in altercation with another dog? *

• Yes
• No

If "Yes" was selected above, please elaborate below (when, how, why). *

Has the dog bitten or scratched a human or another animal within the past 10 days? *

• Yes
• No

If "Yes" was selected above, please elaborate below (when, how, why). *

Describe the dog's personality and habits, e.g. playful, lapdog, enjoys car rides, loves the dog park, separation anxiety etc. Include traits such as marking, chewing, excessive barking, jumping on people etc.

Describe the dog's favorite activities.

What type of obedience training has the dog received? Select all that apply.

• Professional
• Home
• None

Does the dog know any basic commands? Select any that apply.

• Sit
• Stay
• Wait
• Come
• Heel
• Down
• Speak
• Roll over
• None

Is the dog kept outside?

• Yes
• No

Has the dog ever escaped?

• Yes
• No

Does the dog jump fences?

• Yes
• No

Does the dog dig under fences?

• Yes
• No

Is there anything else we should know about this dog?

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Declaration

Please acknowledge the following by checking each box. *

• I hereby certify that I have legal ownership of the dog who is the subject of this Owner Surrender Form and have full right to surrender the dog.
• I certify that no other person has a right of ownership to the dog.
• I hereby surrender any and all rights of ownership of the dog listed herein to Lend A Helping Paw Shih Tzu Rescue (LAHPSTR).
• I understand that once I relinquish the dog, I cannot ask for the dog back and the dog may not be returned to me.
• I certify being of legal age (over 21).
• I also agree that any outstanding veterinarian bills related to the dog listed herein prior to surrender is the sole responsibility of the surrendering individual or family.
• I further certify that I have read, fully understand and agree to the terms of this Owner Surrender Form.

By signing this Owner Surrender Form electronically, I agree that my electronic signature is the legal equivalent of my manual signature on this Owner Surrender Form.

Signature *

Clear Signature

Date *

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Phone

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