Dog Surrender Form

Contact Name *

First

Last

Contact Phone Number *

Contact Email Address *

Where is the dog currently located? *

Please note that Heartland Animal Shelter is located in Northbrook, IL.

Dog's Name *

Dog's Breed *

Dog's Age *

Gender *

Male
Female

Spayed or Neutered? *

Yes
No

Breed Size *

Small
Medium
Large

Approximate Weight *

Where did you originally adopt or purchase your dog from? *

Date of last canine distemper vaccine? *

Date of last rabies vaccine? *

Date of last heartworm test? *

Date of last heartworm preventative administration? *

Date of last flea/tick preventative administration? *

Veterinarian Name/Clinic Information *

Please note that a copy of your dog's medical records is required for consideration.

Why do you wish to surrender your dog? *

Does your dog have any health issues? *

Is your dog on any medications? *

What food does your dog eat? *

Who is in your household with the dog? *

Adults
Teenagers
Children Under 13

Is your dog house trained? *

Yes
No

After how many hours will your dog have an accident if left alone? *

Is your dog paper trained? *

Yes
No

How many hours is your dog left alone each day? *

Where is your dog kept when alone? *

My dog is good with (check all that apply) *

Kids
Dogs
Cats
Strangers

How does your dog behave around other dogs? *

Check all that apply.

How does your dog behave around cats? *

Check all that apply.

How does your dog behave around strangers? *

Check all that apply.

How does your dog behave around children? *

Check all that apply.

Does your dog know any commands? *

Sit
Down
Stay
Shake

Check all that apply.

Has your dog ever bitten anyone? *

Yes
No

Is your dog good on a leash? *

Yes
No

How does your dog behave on a leash? *

Check all that apply.

Please include a brief overview of the situation, including any behavioral and/or medical issues so we can best assist you and your dog's needs. *

Please understand that your inquiry will go unanswered without all of the above information provided.

Photo of Dog

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