Surrender Intake Form

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First Name
Last Name
Street Address
City
State
Zip Code
Email
Phone	Your primary contact number
Call Time	Best time(s) to reach you at the phone number provided.
Dog's Name
Age of dog	Indicate Years and month. Example 1 yr 5 months
Weight (lbs)	If unknown then indicate "unknown".
Breed	Breed Golden Retriever Pure Golden Retriever Mix Lab Retriever Pure Lab Retriever Mix Unknown other: Select what best describes the breed of dog being surrendered.
Birthdate	Full birth date or year. If unknown then indicate "unknown".
Gender	Gender M F
Spay or Neutered	Spay or Neutered Yes No Unknown
Is dog micro-chipped?	Is dog micro-chipped? Yes No Unknown
Dog obtained from	Dog obtained from Breeder Pet Store Shelter ECGRR other:
If Breeder - will they take back?	If Breeder - will they take back? Yes No N/A Please check N/A if no Breeder is involved.
Do you have AKC papers?	Do you have AKC papers? Yes No
Reason you are surrendering dog
Current on Vaccines/Shots	Current on Vaccines/Shots Yes No Unknown We ask for copies of any shot records you have. ECGRR will update vaccinations as needed.
Date of last Vet visit/exam	(MM/DD/YYYY) If unknown then indicate unknown.
Using regular flea preventative?	Using regular flea preventative? Yes No Unknown
Heartworm Medication	Heartworm Medication Yes No Unknown
Heartworm Med Name	Med brand name
Last Heartworm Test	(MM/DD/YYYY) Indicate date or if unknown
Heartworm Test Results	Heartworm Test Results Negative Positive Pending
Name/Address/Phone of your Vet	Please also list the name of the vet that has this dogs health records if different from your regular vet. If unknown then indicate "record location unknown".
Indicate any known Medical conditions	Indicate any known Medical conditions None Seizures Allergies Hypothyroidism Heart Murmur Diabetes Hip Dysplasia Arthritis Unknown other:
Indicate any signs of:	Indicate any signs of: None Hot Spots Fleas Shaking Head Scratching Open Sores Constant Panting Diarrhea Vomitting Bloody Stools Coughing
Any food or toy aggression?	Any food or toy aggression? Yes No Unknown This would be any signs of actual agression towards people or other dogs. Do not include play behavior
Has dog ever bitten another dog or person?	Has dog ever bitten another dog or person? Yes No Unknown Select either Yes, No or Unknown. Understand any attempts to mislead or falsify information will result in your dog being denied acceptance into ECGRR. If the answer is Yes please explain in the next section.
If prior bite - details:	Please explain the circumstances that made the dog bite.
Please select all that apply to the dog	Please select all that apply to the dog Good with children Good with dogs Good with cats Housetrained Obedience trained Destructive Leash trained Crate trained Good when left alone Comes when called Afraid of loud noises Separation Anxiety Barks excessively Knows a few basic commands Likes the water Likes to fetch None other:

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