Owner Surrender Form
 
THERE ARE MANY COSTS ASSOCIATED WITH FINDING A GOOD HOME FOR YOUR DOG. WE APPRECIATE A DONATION TO HELP ASSIST WITH THESE COSTS AND ASK THAT YOU BRING YOUR DOG UP TO DATE ON SHOTS AND SPAY/NEUTER THEM.

Please attach a copy of all veterinary records, along with current rabies certificate and a copy of AKC and microchip papers (where applicable).

Please answer each of the following questions as honestly as possible. There are no “right” or “wrong” answers.

 
Name of Golden:
Age:
How much does dog weigh?
Male:
Female:
If female, has she had any litters? Yes No
If so, how many?
Date of last litter?
Has this Golden ever bitten anyone? Yes No
How long have you had the Golden?
Age when acquired?
Where did you acquire the dog?
Do you have a verbal or written agreement with the breeder or previous owner?
Does the dog have a microchip? Yes No
What is the reason for giving up this dog?
Name, address and phone number of veterinarians:
May we contact the vet for verification of treatment? Yes No
Is dog current on all vaccines? YesNo
Is dog current on a Bordatella shot? YesNo
Date of last heartworm test:
Was the result positive or negative? PositiveNegative
Has the dog received heartworm preventative? Yes No
Date:
Brand:
Is the dog spayed/neutered? Yes No
If yes, when?
Where?
Date of last fecal check for worms?
Result?
What medical conditions does this dog have that a new owner should know about?
Does the dog have any skin problems, allergies or hot spots?
Has this dog had any surgeries?
Is the dog housetrained? Always Almost always Partly No
Does the dog “ask” to go outside? If yes, how?
What is the dog’s activity level? Low Medium High
How difficult is it to walk this dog? Easy Moderate Difficult
Is this dog used to: Being walked Tied out Running loose Crated?
If this dog gets loose, how difficult is it to get the dog to return? Easy Not too Hard Difficult
What does this dog dislike?
What is this dog afraid of?
Where does this dog sleep?
Is dog allowed on furniture? Yes No
Where is this dog left when alone?
How many hours can this dog be alone?
Does this dog: Chew Bark incessantly Dig Jump fences Protect food Protect toys Submissive wetting
What commands does the dog know? Sit Stay Come Off Down
How does the dog react to other dogs?
How does the dog react to cats?
How does the dog react to strangers?
How does the dog react to children?
Do you have children? Yes No
How many children are in your home?
Children's Ages?
Can you grab the dog by the collar?
Can you touch the dog anywhere?
Has the dog ever growled at a person?
Does the dog like to: Ride in the car Swim Go running
How often do you feed the dog? 1x 2x Leave food out
What type of dog food do you use?
Is this dog possessive of food bowls?
Can you take food out of the dog’s mouth or touch food while eating?
What types of correction methods have you tried? Corrective collar? If so, what type
Confinement? If so where?
Rolled up Newspaper?
Scream Stop/No?
Smack with hand?
Other? Please describe
How would you describe this dog? Family dog One person dog Shy Friendly Destructive Active Quiet Playful Aggressive Noisy Obedient Easy Going Other
Please list any other information that might be helpful to new owners.
Owner’s Name:
Date:
Address
City
State
Zip
County
Daytime Phone
Evening Phone
Cell Phone
Email Address
How did you hear
about us?
I, being the owner of the dog listed above, hereby guarantee that all information stated above, in relation to this dog’s history with regards to biting, growling, or any other act of aggression, has been accurately described above. I understand that should Adopt a Golden Atlanta, Inc. take ownership of the dog and should determination ever be made that the biting/growling history of this dog be proven to have been misrepresented, then I will be solely responsible for any costs, attorney fees, and medical/surgical bills resulting from my misrepresentation of the dog’s prior history. I certify that I am the sole owner of this dog (if there are co-owners, all co-owners must also sign this document). I understand and agree to the above conditions in this document.