First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Cell Phone

Alt Email

Basic Information Collection Section

What is the Guardians First and Last name? (This is in case it is different from the person submitting the form) *

When was the dog adopted?*

What was the age of the dog at the time of adoption?*

What is the CURRENT age of the dog?*

Dog's adopted name?*

Dogs Current Name (in case it has been changed)?*

Reason For Return Section

Reason for Return?*

If there is a time limit, what is the date need to surrender by? If none, please write "none".*

If we could resolve the issue, would you consider keeping the dog?*
Choose one: Yes No Possibly

Veterinarian Info and Medical Information Section

Date of last vet visit?*

Name of vet?*

Vet Phone Number?*

Is the dog currently on heartworm or flea prevention? Please describe.*

Date prevention last given? *

Is your dog on any other medications other than preventatives mentioned above?*

Are there any Medical Concerns?*

Behavior and Home Life Information Section

While in your care, did this dog live with other dogs, cats or children? Any concerns?*

Any behavior concerns not already mentioned?*

While in my care, this animal bit someone?*
Choose one: Yes No

If yes, please describe.

What makes your pet the happiest?*

What upsets your pet the most? *

What else should we know about your dog?*