Surrender Intake Information

Name of Dog*

Gender* Male Female

Spayed/Neutered?* Yes No

Color of Dog

Age of Dog

Owners Name*

Street Address*

City*

State*

Zip Code*

Phone Number*

Email Address*

Medical Information

Name of Veterinarian*

Name of Animal Hospital*

Animal Hospital's Address*

Animal Hospital's Phone Number*

On Heartworm Preventative?* Yes No

Date of Last Treatment

Current on Rabies Vaccine?* Yes No

Date

Current on DHLPP Vaccine?* Yes No

Date

Current on Bordetalla Vaccine?* Yes No

Date

Please list any past surgeries, severe illnesses, or any past or present medical conditions (allergies, thyroid, diabetes, etc)

Is the Golden currently on any medications?* Yes No

Please list the medications

Has the Golden been on flea and/or tick prevention?* Yes No

What brand and when was it last given?

Temperment/Personality

Has the Golden ever bitten a person?* Yes No

Please explain the specific situation

Has the Golden ever growled at a person or shown any other signs of aggression?* Yes No

Please explain the specific situation

Has the Golden ever attacked or shown aggression towards other animals (dogs, cats, etc)?* Yes No

Please explain the specific situation

Please add any comments about the dog's general temperment or personality.

Why are you giving up the Golden?*

General Information and Care Routine

How long have you owned the Golden?

What brand of Dog Food has the Golden been eating?

How often do you feed the Golden? Once Twice Daily Free Feed Other

Morning or Evening? Morning Evening

Please elaborate...

Are there certain toys or treats the Golden prefers?

Is the dog crate trained? Yes No Uknown

Does the dog counter surf? Yes No

Is the dog housebroken? Yes No

Does the dog signal to go outside? Yes No

What's the signal?

How does the Golden react to a bath?

Please upload at least one photo of the dog.*

Our Veterinary Release will appear on the next page after you hit "Next"

Release of Veterinary Information