Surrender Form

Patches Animal Rescue, Inc.

WI Boxer Rescue, Inc.

Thank you for contacting Patches Animal Rescue, Inc and/or WI Boxer Rescue, Inc. about surrending a pet. Provide as much information as possible and complete all the required fields (*).

**We respond to form submissions within 48 hours. If you do not hear from us within that time, email kwaugus@yahoo.com .

About your Pet

Speciies

Dog

Cat

Name of Pet

Age - Breed - Sex

Spayed or Neutered?

Yes

No

How long have you had this pet?

NAME of breeder, rescue, etc.

Why are you surrendering your pet?

Owner Information

Owner #1 First Name

Owner #1 Last Name

Owner #2 First Name

Owner #2 Last Name

Street Address

City / State / Zip

Email. (Verify accuracy! Main means of communication)

Phone

Do you have children under 12 in the home or who frequent your home?

Yes

No

Other

Is your household busy or quiet?

Busy (lots of activity, people in/out)

Quiet (not many visitors)

Other

How many hours are you gone a day? How many hours is the pet home alone?

Who is the primary caretaker of your Pet(s)

List the pets you have owned in the last five (5) years. Provide their name, species, age, spayed or neutered, where you got them from (name of rescue/shelter/breeder) and if they are still with you. We will need to verify that they properly vetted.

If you need more space, please fill in "other" below.

Pet #1

Pet #2

Pet #3

Pet #4

Pet #5

Dog Training and Cues

Have you taken your dog to training classes or work with a trainer?

Yes

No

Other

If Yes, provide business name or name of trainer(s) and location.

Is the dog crate trained? (Stays in crate when gone, likes crate)

Yes

No

Other

Health Information

Proviate the name of all veterinarians that you have used in the last five (5) years. We will contact your vet to verify your current and past pets have been seen annually, sterilized, vaccinated, heartworm tested, etc. CONTACT YOUR VET to advise them we will be calling.

Name of veterinarian/location/phone

Date of last vet exam

Is your dog up to date on vaccinations? (Rabies, distemper)

Yes

No

Other

Do any of your past or current pets had/have any medical considerations? Health problems?

No

Yes, Please list.

Provide any additional information or anything you'd like us to know. You can also attach information at the end of this form.

Please email pictures of your pet to WIBoxerRescue@gmail.com.

Please read and check each box.

As the owner(s) listed above, I/we agree the information provodied is true and accurate to the best of my knowledge.

I give Patches Animal Rescue, Inc or WI Boxer Rescue, Inc. permission to contact the veterinarian(s) listed above.

I understand that if I have ommited any necessary information this might affect my ability to adopt

I verify that I am over 21 years of age.

By entering your name below, you acknowledge you have read and understand all the above statesments.

Proof of vaccinations/other attachments

Proof of vaccinations/other attachements