SURRENDER INFORMATION

Owner Surrender Information

Must be minimum 10 years of age (adjusted by breed)
Must be current on rabies, distemper, and kennel cough vaccines
Must have a current heartworm test and a recent (within 2 weeks) fecal test
Send completed “Owner Surrender” form along with veterinary records and current photograph(s) of the dog(s) to admin@topdogfoundation.org

Please complete the surrender form below. If you wish to download a paper copy and send it to us instead, you can do so here.

Organization Seeking to Transfer a Senior Dog?
Please contact our Program Coordinator for more information admin@topdogfoundation.org

Surrender Form

Owner Name (required)

Address

City

State

Zip

Home Phone

Work/Cell Phone

Email (required)

Can the dog be trusted to stay by itself in the house for extended periods of time?

If not, why?

Does the dog jump fences?

If so, how high?

Has the dog been kept on a chain?

If so, why?

Where does the dog sleep?

When the dog is normally fed?

Where?

What brand of dog food does the dog eat and quantity?

Describe any reaction to grooming (brushing, combing, toe nail clipping, bathing)

Dog’s Name

Breed

Male

Female

Age

Coat Color

Tattoo or Microchip Number (if available)

Registry

Reason for surrender

Age of dog when obtained

Date of Birth

HISTORY

Is the dog primarily
House dogOutside dogBoth

Is the dog housebroken?

If not, why?

MEDICAL INFORMATION

Please attach copies of all vet records including rabies certificate signed by veterinarian

Name of Veterinarian and Clinic

Address of Veterinarian Clinic

Telephone Number

Has your dog been spayed or neutered?
YesNo

Name of Veterinarian providing this service

Please indicate the date of the last vaccination for

RABIES

DHLP

PARVO

CORONA

BORDETELLA

LYME

OTHER

FECAL

Date of last heartworm test

Last heartworm medication (brand and last date administered)

Does your dog have any physical impairments or medical problems that he/she has been treated for?

Any past injuries?

List current medications

TEMPERAMENT

The Owner hereby states that this dog has not bitten a human or shown unprovoked aggression towards another domestic animal.

(Owner’s initials)

OR

Describe in detail any situation where this dog has bitten a human or shown aggression towards another domestic animal (attach additional pages as necessary).

BEHAVIORS
Barks/Howls/WhinesDumps TrashDigsJump on PeopleMark its TerritoryRoams

ACCEPTANCE
Handles StepsWalk on LeashCrate TrainedRides Well in CarTears Furniture/Carpet

FEARS OR NEGATIVE REACTIONS
BicyclesCatsChildrenFirecrackersLoud NoisesMotor VehiclesPassing CarsReact to UniformsStormsStrangersVacuums

How would you describe your dog?
ActiveAggressiveDestructiveEasy GoingFriendlyNervousNeuroticReservedShyStubbornNoisyObedientOne Person DogPlayfulProtectiveQuiet

Age of children dog has been regularly exposed to and dog’s reaction?
Baby to 5 yrs5-910-13Older

Reaction to strangers?

Strong preference for a male vs. female human? Which?
YesNo

Attended any obedience classes or other training?
YesNo

To what level?

Commands that your dog responds to or knows
SITDOWN/DROPSTAYHEELSHAKEROLLOVER

Others

Source of Dog
FriendPet ShopGiftStrayBreederAnimal ShelterAbandonedOther

Explain if other

Please give name, address, and telephone number if your dog was obtained through a Shelter, Rescue Group, Breeder or Pet Shop

What attracted you to this dog at the beginning?

DONATION

Would you like to make a donation to Top Dog Foundation?
YesNo

SURRENDER INFORMATION

Surrender Form

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