Surrender

Owner Information

Name*

Phone*

Email*

Address

Street Address City State Zip Code

Dog Information

Name of Dog*

Age of Dog*

Gender*

Male

Female

Neuter Status*

Neutered / Spayed

Unaltered

Breed*

Purebred

Mix

Specific Breed or Mix of Breeds, if known

Color(s)

Lives Indoors or Outdoors

Indoors

Outdoors

Does the Dog Live with Children?

Yes

No

If yes, what are the age(s)?

How long have you owned the dog?

Reason for surrender

Has breeder (if any) been contacted?

Yes

No

N/A

Current Veterinarian Name and Phone Number

** I give my permission to Jax’s Labrador Retriever Rescue to contact my vet to discuss my dog(s)

Yes

No

NOTE: Please have copies of veterinary records for Jax’s at the time of theevaluation.This includes vet notes fromvisits, vaccination records, care, surgery or medication records and testresults.

Is dog up to date on Distemper Combination/DHLPP?

Yes

No

Is dog up to date on Rabies vaccine?

Yes

No

Does Dog Get Shots For Bordatella/Kennel Cough?

Yes

No

Does Dog Get Shots for Lyme Disease?

Yes

No

Date of last heartworm test:

Result of test:

Positive

Negative

Date of last heartworm meds.:

How often given:

Brand of Heartworm Meds:

Has Dog Been Lyme Tested:

Yes

No

If yes, date of Lyme Test

If Yes, Result of Lyme Test:

Positive

Negative

List and explain any past or present medical or behavioral diagnosis/issues, treatments and medications. Include associated current costs involved.

Does the dog have a bite history or ever shown signs of aggressive or possessive behavior?

Yes

No

If yes, explain the circumstances and details:

What are your dog’s positive characteristics?

What are your dog’s negative characteristics?

Provide any needed details about the above question:

Check One:

I am able to keep my dog for as long as it takes to find him/her a new home

I am not able to keep my dog for more than a specified period of time *

I must find a new home for my dog immediately.

*Specify period of time that you can keep your dog for prior to surrender

Are you willing and able to take the dog back should a placement be unsuccessful?

Yes

No

If no, please explain:

If someone else can take the dog back in your place, please provide their name, address and phone numbers here:

Please attached photos of your dog.

I have reviewed and understand the details of the surrender process and fees involved as outlined on the Jax’s website and/or surrender form.*

Yes

No

This questionnaire has been completed to the best of my knowledge. I have disclosed all medical and/or behavioral history in regards to the above-mentioned dog and agree to make Jax’s aware of any changes with medical or behavioral history immediately. I also understand once the Owner Surrender Agreement is signed, I am waiving all rights of ownership and/or reclaiming of the dog.*

Yes

No

Name of Person Completing This Questionnaire*

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SURRENDERING YOUR DOG

Steps to surrendering your dog:

Owner Information

Dog Information

ADOPTING FROM JAX'S:

HOW YOU CAN HELP: