Canine Surrender Form

(Canine Estates only accepts dogs 25 lbs. and under.)

Full Name:

Your Address:

Address line 1


Address line 2


City

State / Province

Zip / Postal Code
Your Phone Number: Area Code - Phone Number
Your Email Address:

Medical Information:

Name of Veterinarian:
Veterinarian's Number: Area Code - Phone Number

Veterinarian's Address:

Address line 1


Address line 2


City

State / Province

Zip / Postal Code
What is your dog's name?
What is your dog's breed?
What is your dog's weight?
What is your dog's age?
Is your dog spayed or neutered?
If not, what was the date of the last heat cycle?
Is your dog current on DHPP & Rabies Vaccinations?
Date of last test for Heartworms:
Describe any health problems your dog is experiencing:
List any medication(s) your dog is taking:
Describe your dog's experience with children under the age of 6 years old:
How does your dog respond when meeting people for the first time?
When you are away from home, where does your dog stay?
Where does your dog sleep at night?
Does your dog use pads in your home for toileting?
Does your dog use a doggie door to go outside?
What commands does your dog know?
Describe how your dog walks with a leash (distance & frequency):
Has your dog ever shown any food or toy aggression?
If yes, please describe:
Has your dog ever shown aggression such as growling, snapping or biting?
If yes, please describe:
Has your dog ever bitten a person?
If yes, please describe the event:
Describe the ideal adoptive family for your dog.
(example with or without children, other dogs or cats, house atmosphere)
How did you hear about Canine Estates?
Please feel free to add any information that you feel may be relevant or helpful in selecting the best adoptive home for your dog.