Surrender

Intake Surrender Form

Having to consider relinquishing your dog is not an easy thing to think about. So much can happen that brings this up. We are so glad you’ve found us! We understand that changes in living situations, someone crossing the rainbow bridge before their pet, divorce, health issues of owners and many other reasons come into play. We aren’t here to judge your situation, just to help.

We provide a loving foster home and will have your doxie checked at the vet. When they’re ready we do our very best to make the perfect match for their forever family! If you have questions please contact us

Owner Name *

First

Last

By filling out this form you are doing so as the legal and sole owner of the dog listed and there are no co-owners, nor any other person(s) who have a legal right or interest to the dog you are surrendering. When the dog is physically surrendered we will verify your photo ID (please have one of the following forms of ID available: drivers license, state ID or military ID).

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone *

Email *

Why are you surrendering this dog? *

Please share why the dog is being surrendered.

About the Dog

Number of Dogs *

• Single Dog
• Bonded Pair

If you are surrendering more than one dog, please fill this form out for each dog. Thank you!

Dog's Name *

NOTE: All of the questions on this form will help us find a foster for your dog faster. It will let us help your dog have a smoother experience as they prepare for their new forever family. ❤️

Upload Dog's Photo *

Click or drag a file to this area to upload.

Please feel free to share more than one photo of the dog. Drag and drop the file to add more than one.

Dogs Age/Birthdate *

Dachshund Breed Details *

Standard, miniature, doxie-mix, short hair, long hair, dapple, black and tan, etc.

If a mix, what dog breeds?

We are able to accept dachshunds and doxie-mixes.

Gender & Spay/Neuter Status *

• Female (Not Spayed)
• Female (Spayed)
• Male (Not Neutered)
• Male (Neutered)

Have they had any litters? If so how many?

Female Dogs: Has the dog been bred?

If so, do you know how many litters? Do you know if she was kept in a kennel or crate?

If not spayed, when will they go into heat again?

Dog's Health & Behavior *

Let us know how your dog is doing as a whole. Do they have any behavioral issues?

Has the dog bitten anyone? *

• Yes
• No

Microchip? *

• Yes
• No

Microchip # and provider (if known) *

Crate Trained? *

• Yes
• No

Is this dog good with *

• Men
• Women
• Children
• Other dogs
• Cats

If this surrender is due to biting, fear, or aggression please provide accurate details. *

Please explain what seems to trigger this behavior?

Bad habits the dog has? *

Velcro dog, anxiety, barking, unsocial, digger, biting, possessive, potty training issues, etc. This helps our fosters be prepared for the dog.

Where does the dog sleep usually? *

Food *

What food has the dog been eating? Dry or soft food? Brand? Do they have a special diet?

Medical

Weight *

Is the dog vaccinated? *

• Yes
• No
• Not sure

Vaccinations *

• Rabies Vaccine
• DAP Vaccine (Distemper, Adenovirus and Parvovirus)
• ProHeart 6
• ProHeart 12
• Kennel Cough and Flu Vaccinations (Bordetella Bronchiseptica, Canine Parainfluenza Virus, Canine Influenza Virus-H3N8 and Canine Influenza Virus-H3N2)

Select vaccinations the dog has been given. If possible, please provide the medical records with the dates of their last vaccination. This saves our volunteers a lot of time and prevents doubling up on vaccinations.

Does the dog have any of the following? *

• Cushings
• IVDD
• Diabetes
• Yeast infection
• Other

Note this does not mean we won’t take the dog. We just need to know how they need to be cared for.

Other Medical issues *

Is the dog on a prescription? *

Please add medication names here.

Is the dog currently ill?

Please let us know the details, if they have been diagnosed by the vet. So we can understand what care they need as they come to our rescue.

Veterinary Office Name *

Veterinary Phone Number *

Veterinary Office Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Dog's Medical Records *

• I will provide all of their medical records
• I only have some of their records
• I do not have any of their medical records

This helps us quickly understand what vet care is needed for the dog(s) when they come to us.

Dog's Medical Records

Click or drag a file to this area to upload.

It is in the best interest of the dog you are surrendering, to provide as much information about their vaccinations, medical records, etc. (pictures of the records work great!)

Have they had a dental? *

• Yes
• No
• Unsure

Date of last dental

Does this dog have allergies? *

• Yes
• No
• Unsure

Details of Allergy

What will the dog be given to RMDR with?

• Microchip Information
• Bed
• Blanket
• Food Bowl
• Water Bowl
• Toys
• Food
• Harness
• Collar
• Rabies Tag
• Sweater

These items will be given to their forever family when the dog is adopted.

How did you hear about us? *

• Internet search (please list search engine below)
• Listing of rescues
• Business card
• In person (at Event)
• Word of mouth
• Other (please note this below)

*If "Other" how did you hear about us?

Signature *

Clear Signature

By executing this relinquishment to Rocky Mountain Dachshund Rescue (RMDR) you agree that this is your legal digital signature and you hereby swear, under penalty of perjury, that you are the legal and sole owner of the dog listed above and there are no co-owners, nor any other person(s) who have a legal right or interest to the dog you listed on this form. Thank you for choosing RMDR.

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