Welcome to GRRSWF

Owner Surrender

Contact Information

First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
-

County*

Country

Email*

Home Phone*

Work Phone
x

Cell Phone

Alt Email*

*=required

Is this an outside dog?

Yes

Best time to call:*

How often do you check for calls?

By what date must you surrender the dog?*

Are you the sole legal owner of the dog?

Yes

Dog's Name:*

Dog's age:*

Gender:*

Is the dog spayed or neutered?*

Color:*

Weight:*

Where did you get this dog?

How long have you had him/her? *

Is it a purebred Golden Retriever?

Yes

Is this a GoldenDoodle

Yes

If dog is neither a Golden Retriever nor GoldenDoodle, what breed is the dog?

Do you have AKC papers?

Yes

Is the pedigree available?

Yes

Is the dog microchipped?

Yes

If microchipped, what is the number?

Are vaccinations current? *

If yes, which vaccinations are current?

DHPP	Rabies
Bordetella

*=required

Is dog on heartworm preventative?

Yes	No
Unknown

If yes, what type of preventative?

When was last heartworm preventative given?

When was last flea/tick preventative given?

Has this dog ever had a seizure?

Yes

If yes, how often does he/she have seizures?

Does the dog have any ear problems/recurring infections?

Yes	No
Unknown

Does the dog have any orthopedic problems (Hip dysplasia, arthritis, stiffness)?

Yes	No
Unknown

If yes, what sort of problems?

Does he/she have any skin problems?

Yes	No
Unknown

If yes, what sort of problems?

Does the dog have any allergies?

Yes	No
Unknown

If yes, what sort of allergies?

If yes, what sort of problems?

Does he/she have any other medical conditions?

Yes	No
Unknown

If yes, what conditions?

I understand that GRRSWF will make every effort to find a loving home for my dog and grant my permission to contact the medical service provider named below and hereby grant permission for the release of all records and information in their possession. It is the owner’s responsibility to ensure that GRRSWF has a copy of the dog’s records prior to, or at the time of, the physical surrender. Please note that GRRSWF will not take possession of the dog unless vet records are provided. Please netter the following information: Veterinarian Name: Telephone Number: Address: City: State: Zip:*

What is the dog's disposition?

Is the dog confident or shy?

Can you take food away?

Yes	No
Unknown

Can you take toys away?

Yes	No
Unknown

Can you take bones away?

Yes	No
Unknown

Does the dog dig?

Yes	No
Unknown

Does the dog chew?

Yes	No
Unknown

Does the dog escape from the yard or house?

Yes	No
Unknown

Does the dog run away?

Yes	No
Unknown

Does the dog jump over or climb fences?

Yes	No
Unknown

Does the dog jump on people?

Yes	No
Unknown

*=required

Does the dog steal food or items from the counters or tables?

Yes	No
Unknown

Does the dog swim?

Yes	No
Unknown

Does the dog ride well in cars?

Yes	No
Unknown

Is the dog housebroken?

Yes	No
Unknown

Is the dog crate trained?

Yes	No
Unknown

Does the dog get along with other dogs?

Yes	No
Unknown

Does the dog get along with cats?

Yes	No
Unknown

Does the dog get along with other animals?

Yes	No
Unknown

Is this dog aggressive to other dogs?

Yes	No
Unknown

If yes, what did the dog do to make you think it didn't like the other dog?

Is the dog possessive over the food dish?

Yes	No
Unknown

Does the dog accept strangers?

Yes	No
Unknown

Does the dog accept men?

Yes	No
Unknown

Does the dog accept women?

Yes	No
Unknown

Does the dog like to chase bikes or cars?

Yes	No
Unknown

Does the dog get along with children?

Yes	No
Unknown

Has the dog ever lived with children?

Yes	No
Unknown

If yes, for how long?

What were the children’s ages?

Is there anywhere the dog does not like to be touched?

How did the children treat the dog?

If yes, where?

Is the dog afraid of thunderstorms?

Yes	No
Unknown

If yes, what does this dog do during a thunderstorm?

Has the dog ever growled at a person?

Yes	No
Unknown

If yes, please describe the circumstances

Has the dog ever snapped at a person?

Yes	No
Unknown

If yes, please describe the circumstances

Has the dog ever bitten a person?

Yes	No
Unknown

If yes, please describe the circumstances

Has the dog ever growled at or bitten another animal such as a dog or cat?

Yes	No
Unknown

If yes, please describe the circumstances

Has the dog ever displayed any other signs of aggression?

Yes	No
Unknown

If yes, please describe:

Does the dog like to grab your arm or clothes (mouthy)?

Yes	No
Unknown

If yes, please explain:

What does the dog dislike?

What is the dog afraid of?

*=required

Has the dog been to obedience school?

Yes	No
Unknown

If yes, which obedience school?

Does the dog know any commands? Please list:

Please describe your training methods:

Have you ever disciplined this dog when he/she has done something wrong? Please describe:

Has the dog ever lived with other dogs?

Yes	No
Unknown

Has the dog ever lived with cats?

Yes	No
Unknown

Is this dog used to being home alone during the day?

Yes	No
Unknown

If yes, how many hours on average?

Does the dog have separation anxiety?

Yes	No
Unknown

If yes, how do you handle it?

How do you exercise the dog? How often?

What kind of food is the dog eating now?

How often is he/she fed?

Is the dog on any vitamins or supplements?

Yes	No
Unknown

If yes, please list:

Why are you giving up this dog? (Please be as detailed as possible)

What are the dog's bad points? Please be as honest as possible - we know he/she may not be perfect but the more we know about him/her, the better we are able to select a suitable foster home and then the very best permanent home for him/her:

What are the dog's good points? Again, the more we know about him/her the easier it is to find the perfect home for him/her.

Is there anything else that you would like us to know about the dog?

*=required

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