Golden Retriever Rescue and Community Education
Owner Surrender / Intake Questionnaire
Please type in answers to ALL fields. When finished please submit this form for review.
Owner Information
Owner's name(s):
Owner's address:
Email address:
Telephone number:
Dog Information
Dog's name:
Male
Female
Dog's age:
Housebroken:
Always
Almost Always
Partly
Not at All
Spayed or neutered:
Yes
No
Veterinarian's/clinic's name:
Veterinarian's address:
Veterinarian's phone number:
Date of last vet visit:
Date of last heart worm test:
Heart worm result:
Positive
Negative
Date of last DHLPP:
Date of last rabies shot:
Date of last Bordetella shot:
Date of last fecal specimen:
Result:
Date of last heart worm preventive dose given:
Brand of preventive dose:
Does your dog have any health issues?
Yes
No
If yes, please list them:
Does your dog take any medicines other than heart worm preventive?
Yes
No
If yes, please list them:
Does your dog have a microchip?
Yes
No
Microchip number:
Can we contact your vet?
Yes
Vet name:
Vet phone number: