Surrender Profile Form

Contact Information

Your Name: *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email: *

Cell Phone: *

The best way to reach me is: *

Call me (I check my voicemail)
Call me (I do not check my voicemail)
Text me
Email me

Basic Dog Information

Dog's Name: *

Dog's Age *

Months/Years *

Gender: *

Date of Birth (if known/or estimated)

My dog is a pure bred Shiba Inu: *

My Shiba is mixed with: *

Approximate weight (lbs): *

My dog is up to date on vaccinations *

My dog is microchipped *

The microchip number is: *

Please describe any health concerns, and list any medications your dog is currently taking.

i.e. - My dog has seasonal allergies and needs an antihistamine in the summer, my dog is diabetic and needs insulin injections, my dog has glaucoma, etc.

Please provide the name and phone of your vet clinic *

We will be contacting your vet for copies of your dogs medical records. They may contact you to get permission to release them to us.

If you are not the dog's first home, please tell us what you know about their history, prior to living with you.

My dog is currently eating (brand/flavor of dog food): *

Please upload a photo of your dog *

Click or drag files to this area to upload. You can upload up to 5 files.

The best photos are ones where the dog is facing the camera and we can see their entire body.

Reason for Surrender

Please describe the reason for surrendering your dog *

PLEASE NOTE: It's important for you to be honest and forthcoming about your dog’s history, health, and behavior, no matter how bad. The more we know, the better equipped we are to find the best possible home for your dog. **If your reason for surrender is a pending move, please include your move date**

Please confirm that you are the current legal owner of the dog, and therefore have the authority to surrender the dog to rescue:

I am the sole owner of the dog
I am a co-owner of the dog and am authorized to surrender
I am contacting the rescue on behalf of the legal owner, and am authorized to surrender
I found this dog stray and have been unable to find the owner

Home Environment

My dog currently lives in: *

Please describe the height and type of fencing you currently have. *

Has your dog ever escaped your yard? *

Please describe the circumstances of your dog's escape(s): *

The ideal living environment for my dog would be: *

How many hours is your dog left home alone typically? *

Where does your dog spend their time when home alone? *

i.e. - in their crate, loose in the house, outside, etc.

Where does your dog sleep at night? *

i.e. - in their crate, loose in the house, outside, etc.

Please describe your dog's current exercise routine. (Type of exercise and how frequently)

ie. - we go for one 30-45 minute walk every day, or we play fetch in the yard for 20 minutes a day, or they run around the yard but get no additional exercise, etc.

Social Skills

My dog has lived with other dogs *

When meeting other dogs, my dog: *

is dog friendly, likes every dog they meet
generally ignores dogs, but doesn't have a problem with them
is hit or miss, depends on the dog
is dog reactive or aggressive
unknown

Has your dog ever fought with another dog? *

The result of any dog fight(s) include:

No injuries, only found saliva on either dog
The other dog had a minor puncture wound
The other dog had a minor skin tear
The other dog had a deep puncture wound, needed medical attention
The other dog had a bad skin tear, needed medical attention

Choose all that apply

My dog has lived with cats *

My dog has lived with children *

How old are/were the kids they've lived with? *

How does your dog react when exposure to children? *

Has your dog ever shown any kind of aggression towards people? *

i.e.-bared teeth, growled, lunged, snapped, or bitten a person

Please describe the circumstances causing your dog to show aggression towards a person *

My dog's bite resulted in: *

just scrapes and/or bruising
a minor puncture wound
a minor skin tear
a deep puncture wound, needed medical attention
a major skin tear, needed medical attention

You can choose more than one answer, if multiple bites

Training and Behavior

My dog is house trained *

House trained means only goes potty outside, not on pee pads, or fake grass, etc.

Under what circumstances would they have an accident? *

My dog is crate trained *

My dog is a "bolter" (will run out of an open door)

My dog is a resource guarder (food/toy aggression)

Choose all that apply

My dog is:

an excessive digger
an excessive chewer of inappropriate items
an excessive barker/howler
anxious when I'm not home
destructive or too vocal in the crate

Choose all that apply

Comments/Questions:

Anything else you think we should know about your dog? Questions about the surrender process?

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Contact Information

Basic Dog Information

Reason for Surrender

Home Environment

Social Skills

Training and Behavior

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