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********************************************************** Owner Name(s): ___________________________________________________________ Address: ___________________________ Phone #:______________________________ City:________________________________________State__________Zip:____________ Dog’s Name: ____________________________________Age: ________Sex: M or F Color: ____________________________Coat type/Markings:_____________________ AKC Registration #:___________________________ Microchip #:_________________ Breeder Name/Address:____________________________________________________ CURRENT HEALTH: Spay/Neutered Yes______ No _______ date completed?________________________ most recent vaccination date:___________________rabies date:_________________ heartworm status:_____________________________last tested?___________________ Has your dog been diagnosed with a current / recurring illness or injury? YES or NO (please circle) If yes, please describe:_____________________________________________________ _________________________________________________________________________ TEMPERAMENT: Please answer yes/no and give short description w/adults:_________________________________________________________________ w/ children_______________________________________________________________ w/ other dogs_____________________________________________________________ w/ cats___________________________________________________________________ w/ other animals__________________________________________________________ I, __________________________ do hereby surrender the above named and described dog to _____________ on ____/____ /_______. By surrendering this dog, I relinquish all claims / rights to the disposition of the animal. I release any and all claim to said animal and understand that I may not have the dog back nor inquire into the disposition of same. I authorize the release of any medical records pertaining to said animal for the purpose of helping to place the animal (or euthanize if necessary). I also acknowledge that the dog has not bitten anyone or know of any unmentioned medical conditions to the best of my knowledge. I have given, to the best of my knowledge, true and correct information as to the age, condition and temperament of the animal. In consideration of rehoming services in the disposition of this animal, I contribute $_______________________ to assist in this process. Signed: ____________________________________ Date: _______________________ print name: ________________________________ Signed: ____________________________________ Date: _______________________ print name: ________________________________ |