Owner Surrender Form

I have read the above and will answer the following questions honestly and to the best of my ability.(Required)

Yes

Please input your information below

Your Name(Required)

Your Email(Required)

Mobile Number(Required)

Your Address(Required)

Please provide your dogs details below

Dog's name(Required)

Age(Required)

Breed (Give an idea of what breed)(Required)

Gender(Required)

Female

Male

Is your dog neutered?(Required)

Yes

Are the dogs vaccinations up to date?(Required)

Yes

Unknown

Are you the dog's first owner?(Required)

Yes

If no, how long have you owned him/her?

Where did you get your dog from?(Required)

Has your dog ever been the victim of abuse or neglect?(Required)

Yes

If yes, please provide details

Is your dog microchipped?(Required)

Yes

If yes, what is their microchip number

Has your dog any illnesses, injuries or previously had surgery (other than neuter/spay)(Required)

Yes

Unknown

If yes, please provide details

Is the dog currently prescribed any medications or taking any supplements?(Required)

Yes

Unknown

If yes, please provide details

What is the name of your current vet

Last dewormed date(Required)

DD dash MM dash YYYY

What brand of food do they eat?(Required)

Please be fully honest with us.

Please outline the reason why you want to surrender your dog to us?(Required)

Is your dog toilet trained?(Required)

Yes

Unknown

Is your dog lead trained?(Required)

Yes

Pulls strongly

Is your dog crate trained?(Required)

Yes

Unknown

Is your dog used to walking with

Lead & Collar

Lead & Harness

Other

Does your dog know any commands (Sit/lie down/stay etc)

When you are away from home, the dog is:(Required)

Has your dog ever shown any signs of aggression?(Required)

Yes

If yes, please provide details

Has your dog ever bitten a person?(Required)

Yes

Unknown

Has your dog ever bitten another dog?(Required)

Yes

Unknown

Does your dog suffer from separation anxiety?(Required)

Yes

Unknown

Is your dog okay travelling in a car?(Required)

Yes

Unknown

Is your dog good with other dogs?(Required)

Yes

Unknown

Is your dog okay around cats?(Required)

Yes

Unknown

Is your dog fearful of..... (Select all that apply)(Required)

Women

Men

Children

Strangers

Vet

Groomer

Other dogs

Walking on busy roads

Walking near cars

Cyclists or buses

None

Did your dog live in a home with children?(Required)

Yes

Unknown

Please provide ages of children

Have you ever attended training classes with your dog?(Required)

Yes

If yes, please provide trainers name

Where does your dog sleep at night?(Required)

Additional Information

Please provide any other additional information, being completely honest in order for us to place your dog in the correct home. Add details on your dog’s likes / dislikes / personality / temperament / travels well etc.

I confirm that all the information I have provided above is true and complete to the best of my knowledge.(Required)

Yes

I agree to Dogs In Distress processing my information for the purpose of surrendering my dog.(Required)

Yes

Please upload a picture of your dog.(Required)

Accepted file types: jpg, png, Max. file size: 64 MB.

Please upload a picture of your dog.

Accepted file types: jpg, png, Max. file size: 64 MB.

Please upload a picture of your dog.

Accepted file types: jpg, png, Max. file size: 64 MB.

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