First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Cell Phone*

Alt Email

What is the name of the dog who is being surrendered?

Is the dog a male or female?*

What is the age of the dog - if not sure, give an estimate. Is this dog very young, very old - or an adult. Your vet can help to estimate the age of an adult dog. The dog's teeth also help to give us an estimate of its age.

Is this a mixed breed Yorkie and if so, what is the other breed?

How much does the dog weigh?

Where did you get this dog? If it was from a rescue or shelter, you must contact them if you can no longer keep the dog. You cannot give the dog to anyone else. Please contact the shelter or rescue where you adopted the dog.*

Please provide the name, address and phone number of the vet who has seen this dog. We need a copy of all vet records, please ask your vet for a copy of these records to pass on to the new guardians. Name: Address: Vet's phone number:

Does this dog have a current rabies certificate? By federal law, all dogs coming into rescue must have a current rabies certificate. *

Does the dog have a current Distemper/Parvo vaccination? *

Is the dog spayed or neutered?*

Is this dog microchipped? If so, list the Manufacturer and Chip Number. *

Does this dog have any serious health issues that we need to be aware of, such as allergies, broken bones, or diabetes?
Choose all that apply: Yes No Maybe

Has the dog been tested for heartworm? When was the test performed? Has the dog been taking a heartworm preventative? When was the last time it was given?*

Does this dog get along with other dogs? State if there is aggression due to food or toys or any other trigger.

Has the dog had experience with cats? Does the dog chase cats or ignore them?

Does the dog walk nicely on a lead?

Does the dog ride well in the car? Does the dog enjoy riding in the car or does he or she get car sick? If yes, have you tried Cerenia to prevent car sickness?

How does the dog react to strangers?

Does the dog do well alone? Any separation anxiety?

What are you feeding this dog? How often? How much? Any special dietary needs?

What does the dog like best? cookies, car rides, walks, other dogs, naps...

What does your dog like least? Grooming, being alone, other dogs, being in the car? thunder storms? strangers?

What does your dog fear? Strangers? Men? Big dogs? being alone?

Does this dog have bad habits that we need to know about? Please describe in detail.

How does the dog react to children?

Has your dog bitten a human or a dog? Small children? Broken skin? more than once?*

Has your dog ever bitten another dog? *

Where will your dog sleep at night?

Has this dog had any formal training? Describe.

Why do you need to surrender this Yorkie into rescue? *

Give us details to keep this dog happy and healthy. *