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? *
Crate
Outside
In a Room
Loose in House
Other

My dog is good with (check all that apply) *
Kids
Dogs
Cats
Strangers

How does your dog behave around other dogs? *
Plays
Ignores
Growls
Snaps/Bites
Don't Know
Check all that apply.

How does your dog behave around cats? *
Plays
Ignores
Growls
Snaps/Bites
Don't Know
Check all that apply.

How does your dog behave around strangers? *
Friendly
Tolerates
Ignores
Growls
Barks
Snaps/Bites
Check all that apply.

How does your dog behave around children? *
Friendly
Tolerates
Ignores
Growls
Barks
Snaps/Bites
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? *
Pulls
Excited
Walks Calmly
Refuses to Walk
Not Leash Trained
Lunges or Barks at Dogs
Lunges or Barks at Cats
Lunges or Barks at Strangers
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

Click or drag a file to this area to upload.

Adopt

Thank you to everyone to supported Heartland Sweats for Pets!

Vaccine Clinic & Pet Food Pantry

Wear socks to support Heartland

Connect

Help us continue our life-saving mission.

Contact Heartland Animal Shelter