Dog Surrender Form

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About You (The Owner)

Name*

Owner (You) First Name: Owner (You) Last Name:

Your Email Address:*

Your Phone Number:*

Where are you located? (ex: Redmond, Bend, Madras, etc.):*

About Your Pet

Animal's Name:

Animal's Age:

Animal's Breed:*

Animal's Sex:*

Please upload a picture of your animal:

Max. file size: 256 MB.

How long have you had your dog? How did you acquire this dog?*

Why are you surrendering your dog?*

Does your dog have any medical or behavior problems?*

Yes

Please explain your cat's medical or behavior problems:*

Is your dog on any medications or special diet?*

Is your dog up to date on vaccinations?*

Yes

Unknown

Can you provide medical records?

What is your dog's primary veterinary clinic?

Is your dog spayed and neutered?*

Yes

Unknown

If we were able to provide you with a solution for the issue that is causing you to surrender your dog (free food, low cost veterinary care, training, or behavioral help), would you consider keeping your dog?*

Yes

Please explain more about your answer to the previous question:

Pet Profile

What is your dog's personality like? Check all that apply:*

Active

Playful

Affectionate

Friendly

Shy

Independent

Fearful

Destructive

Vocal

Other (explain below)

Explain your dog's "other" personality:

Where does your dog sleep?*

What does your dog eat? (check all that apply):

Dry Food

Canned Food

Homemade Diet

Raw Diet

Prescription

Other (explain below)

Explain your dog's "other" food:*

Please check all that your dog has lived with:*

Children (0 - 12 years)

Teenagers (13 - 18 years)

Adult Men

Adult Women

Senior Citizens (55+ years)

Other (explain below):

Please explain "other":

What is your dog's behavior towards the family members he/she has lived with? Check all that apply:*

Friendly / Playful

Too Active / Hyper

Rough

Gentle

Avoidant

Unpredicable

Ignore Interaction

Fearful / Nervous

Resource Guards / Protective

Other (explain below)

Please explain "other":

What animals has your dog lived with? Check all that apply:

Male Dog

Female Dog

Male Cat

Female Cat

Small Mammals (rabbits, guinea pigs, etc)

Birds

Livestock (chickens, goats, horses, cows, etc)

Other (explain below)

Please explain "other" animals your dog has lived with:

What is your dog's behavior towards other dogs? Check all that apply:

Never has been around other dogs

Friendly / Playful

Too Active / Hyper

Rough

Gentle

Ignores Interaction

Fearful / Nervous

Submissive

Aggressive or Reactive

Resource Guards / Protective

Other (explain below)

Please explain "other" animals your dog has lived with:

What is your dog's behavior towards cats? Check all that apply.

Never has been around cats

Friendly / Playful

Too Active / Hyper

Rough

Gentle

Ignores Interaction

Fearful / Nervous

Submissive

Aggressive or Reactive

Resource Guards / Protective

Other (explain below)

Please explain "other" animals your cats has lived with:

Where is your dog kept while you are not home? Check all that apply:

Never is left alone

Free roam inside

Crate / Kennel

Yard

Tied on a chain / runner

Other (explain below)

Please explain "other":

How long is your dog left alone?

Never

1 - 3 hours

4 - 8 hours

9 - 12 hours

Over 12 hours

Is your dog "house broken"?

Yes

Has occasional accidents

Has your dog ever bitten a person?

Yes

Please explain when it occurred and the circumstances of the bite:*

Has your dog bitten and broken skin on a person within the last 10 days?*

Yes

Has your dog ever bitten another animal?*

Yes

Please explain when it occurred and the circumstances of the bite:

Is your dog fearful of anything? Check all that apply:

Men

Women

Children and/or Teenagers

Strangers

Cars

Bikes / Skateboards

Fireworks

Thunder / Lightning

Yelling / Loud Noisees

Veterinary Clinic and/or Groomer

Other (explain below)

Please explain what "other" things you dog is fearful of:

Is your dog crate trained?*

Yes

Does your dog ride well in the car?*

Yes

Please explain how your dog reacts to treatment/medical care at a veterinary clinic:*

Has your dog escaped or attempted to escape? If yes, check all that apply:*

Never

Jumping

Digging

Open Doors

Chewing

Other (explain below)

Please explain how your dog reacts to treatment/medical care at a veterinary clinic:*

What commands does your dog know? Check all that apply:

Come

Stay

Sit

Lay Down

Shake / Paw

Roll Over

Walks well on a leash

Doesn't jump on people

Other (explain below)

How does your dog react when someone touches their food bowl while eating? (check all that apply):

Unknown

Friendly

Unbothered

Fearful / Afraid

Growls

Bites

How does your dog react when someone takes their bone or treat away? (check all that apply):

Unknown

Friendly

Unbothered

Fearful / Afraid

Growls

Bites

How does your dog react when someone takes their toy or object away? (check all that apply):

Unknown

Friendly

Unbothered

Fearful / Afraid

Growls

Bites

How does your dog react when they are disturbed while sleeping? (check all that apply):

Unknown

Friendly

Unbothered

Fearful / Afraid

Growls

Bites

How does your dog react when they are picked up? (check all that apply):

Unknown

Friendly

Unbothered

Fearful / Afraid

Growls

Bites

How does your dog react when an unfamiliar person approaches? (check all that apply):

Unknown

Friendly

Unbothered

Fearful / Afraid

Growls

Bites

How does your dog react when they bathed and/or are groomed? (check all that apply):

Unknown

Friendly

Unbothered

Fearful / Afraid

Growls

Bites

How does your dog react when their nails are trimmed? (check all that apply):

Unknown

Friendly

Unbothered

Fearful / Afraid

Growls

Bites

How does your dog react when someone hold/restrains your dog? (check all that apply):

Unknown

Friendly

Unbothered

Fearful / Afraid

Growls

Bites

If applicable, please list any other additional information about your dog that will be important for BrightSide to know:*

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Dog Surrender Form