Yorkie Rescue of the Carolinas Surrender Form

First and Last Name: *

Street Address: *

Email Address: *

City, State and Zip Code: *

Home Phone Number: *

Cell Phone Number: *

Dog's Name: *

Dog's Age: *

Dog's Date Of Birth: *

Male or Female? *

Current Weight: *

Breed: *

Reason for surrender: *

How long have you owned your pet? *

Check all that apply: *

Is your dog housebroken? *

Is your dog leash trained?: *

Is your pet microchipped? *

Is your dog crate trained?: *

Where does your dog sleep at night?: *

Is your dog spayed or neutered? *

What is the name of the dog food you are currently feeding your pet? *

Date of last dental cleaning? *

Is your pet on monthly Heartworm Treatment? If so, what brand? *

Has he/she ever been diagnosed with a medical condition? If so, please give details. *

Please list all current medications *

Date of last Vet Visit: *

Veterinarian's name, address and phone number: *

Please list all current health issues and all medical care currently being given: *

Is your dog child friendly? *

Is he/she friendly with cats? *

Has your pet ever done any of the following? Please check all that apply: *

May we refer your request to another reputable group if we are unable to help you? *

Please email us a photo of your pet to YorkieROC@gmail.com with your name, the pet's name, and any pertinent additional information. We will get back with you asap to make arrangements for pick-up. Sign and date: *