SURRENDER INTAKE PROFILE Surrender Thank you for taking the time to thoroughly fill out this form. The information provided by you is important and allows us to make the best possible decision when rehoming your Golden. If there is a red * after the field name that means you are required to enter something in the field. If the field is asking for a number (e.g. phone or fax), please enter a number. If the field is asking for text, you can put NA if not applicable. Dog's Name * Owner * Street Address * City * State * Zip Code * Phone * Cell Phone * Email * Is your dog male or female? * Is your dog male or female?MaleFemale Is your dog spayed/neutered? * Is your dog spayed/neutered?YesNo Age of your dog? * Date of Birth of your dog? * Weight of your dog? * Color of your dog? * Is your dog a purebred Golden? * Is your dog a purebred Golden?*YesNo If No, please identify mixes * Where was your dog purchased/obtained from? * How Long have you had your dog? * Where is your dog currently housed? * Where is your dog currently housed?*InsideOutside Do you have AKC papers on your dog? * Do you have AKC papers on your dog?*YesNo Is your dog micro chipped? Is your dog micro chipped?*YesNo Company brand name * ID# * Veterinary Information Name of Clinic * Name of Veterinarian * Clinic Phone Number * Fax * Please call your Veterinarian to release all medical information on your dog to Golden Treasures Are Vaccinations up to Date? * Are Vaccinations up to Date?*YesNoUnsure Date vaccinations given * Has your dog been heartworm tested * Has your dog been heartworm tested?*YesNoUnsure Date of last heartworm test * Currently on heartworm prevention medication? * Currently on heartworm prevention medication?*YesNoUnsure Name of heartworm medication * Date Last Given * Is your dog currently on any medications other than heartworm? * Is your dog currently on any medications other than heartworm?*YesNo If yes, Name of med, dosage, frequency given * Does your dog have allergies? * Does your dog have allergies?*YesNo If yes, what type and how is it being treated * Does your dog have seizures? * Does your dog have seizures?*YesNo If, yes, date of last seizure * How often? * What treatment is dog receiving for the seizures? * Temperament Briefly describe your dog's temperament * Good with Kids? * Good with Kids?*YesNoUnsure Ages * Housebroken? * Housebroken?*YesNoUnsure Good alone? * Good alone?*YesNoUnsure Destructive * Destructive?*YesNoUnsure Obedience trained? Obedience trained?*YesNoUnsure Crate Trained * Crate trained?*YesNoUnsure Comes When Called? * Comes When Called?*YesNoUnsure Leash Trained * Leash Trained?*YesNoUnsure Has a fence? * Has a fence?*YesNo Type? * Will dog run away if it gets loose? Will dog run away if it gets loose?*YesNoUnsure Chase cars? * Chase cars?*YesNoUnsure Good with cats? * Good with cats?*YesNoUnsure Like other dogs? * Like other dogs?*NoYes, MalesYes, FemalesYes, BothUnsure Accustomed to being alone? * Accustomed to being alone?*YesNoUnsure How long? * Trustworthy in house alone? * Trustworthy in house alone?*YesNoUnsure Afraid of storms/fireworks? * Afraid of storms/fireworks?*YesNoUnsure If yes, what is behavior like? * Rides well in car? * Rides will in car?*YesNoUnsure Exercised frequently? * Exercised frequently?*YesNoUnsure Exercised How? * What is your dog's energy level? * What is your dog's energy level?*1 - Low23 - Medium45 - High Where does dog sleep? * Food/Toy aggressive? * Food/Toy aggressive?*YesNoUnsure If dog is Food/Toy aggressive, please explain * Does your dog jump on people? * Does your dog jump on people?*YesNoUnsure Does your dog do any mouthing? Does your dog do any mouthing?*YesNoUnsure Has your dog ever snapped/growl at people? Has your dog ever snapped/growl at people?*YesNoUnsure If dog has snapped/growled please the explain situation * Has your dog ever bitten anyone? * Has your dog ever bitten anyone?*YesNoUnsure If dog has bitten when was it? * If dog as bitten please explain the circumstances * What food do you feed? * How much food?* * How often is dog fed? * Does you dog have behavioral problems? Does you dog have behavioral problems?*YesNo Explain behavioral problems * Does your dog have any medical problems? (chronic ear infections, hot spots, tumors, etc.) * Does your dog have any medical problems? (chronic ear infections, hot spots, tumors, etc.)*YesNo If yes, please explain medical problems * Reason for relinquishment? * OWNER AGREEMENT THE UNDERSIGNED, BEING THE OWNER OR THE DULY APPOINTED AGENT OF THE ABOVE-DESCRIBED DOG, DOES HEREBY AFFIRM, ACKNOWLEDGE AND WARRANT AND REPRESENT THAT ALL INFORMATION CONTAINED IN THIS PROFILE IS TRUE AND CORRECT TO THE BEST OF THEIR KNOWLEDGE AND BELIEF. SHOULD ANY OF THE INFORMATION SET FORTH BE DISCOVERED TO BE FALSE, UNTRUE OR MISLEADING IN ANY RESPECT AT ANY TIME, THEN GOLDEN TREASURES SHALL HAVE THE RIGHT TO (1) RESCIND THIS AGREEMENT AND REQUIRE OWNER TO TAKE THE DOG IMMEDIATELY INTO HIS/HER POSSESSION AND/OR (2) REQUIRE OWNER TO PAY ALL COSTS INCURRED IN THE CARE, PLACEMENT OR DISPOSITION OF THE DOG. FURTHER, SHOULD ANY OF THE INFORMATION SET FORTH IN THIS DOCUMENT BE DISCOVERED TO BE FALSE, UNTRUE OR MISLEANDING IN ANY RESPECT AT ANY TIME, THEN OWNER AGREES TO INDEMNIFY AND HOLD GOLDEN TREASURES HARMLESS BY, FROM AND AGAINST ANY AND ALL CLAIMS, SUITS, DAMAGES, LIABILITIES AND COSTS (INCLUDING REASONABLE ATTORNEY FEES) RELATED TO OR IN ANY MANNER CONNECTED WITH THIS DOG. I understand that Golden Treasures Golden Retriever Rescue, Inc. will make every effort to find a loving home for my dog and grant my permission to contact all of the medical service providers named above and hereby grant permission for the release of all records and information in their possession. I HEREBY RELINQUISH OWNERSHIP OF THE ABOVE-MENTIONED DOG TO GOLDEN TREASURES. IF, FOR ANY REASON, I DO NOT TURN MY DOG OVER TO GOLDEN TREASURES ONCE I HAVE ASKED FOR THEIR HELP, I UNDERSTAND THAT THERE WILL BE A $50.00 ADMINISTRATION FEE, WHICH I AGREE TO PAY. GOLDEN TREASURES' RESPONSIBILITY FOR THE CARE, PLACEMENT OR DISPOSITION OF THE DOG, OR FOR COSTS INCURRED, WILL NOT BEGIN UNTIL THE DOG IS IN THE POSSESSION OF GOLDEN TREASURES. By typing your name below, you acknowledge that your electronic signature constitutes a legally binding agreement, equivalent to a handwritten signature. Do you agree? * YesNo Digital Signature * Date * Captcha Captcha determines if you are a human submitting this form - please check the box if it is not checked already Submit If you are human, leave this field blank.
