Great Lakes Mastiff Rescue, Inc. (GLMR) Dog Surrender Form

Personal Demographics

Name:

Street Address:

City: State: Zip Code:

Home: Area Code: Phone Number:

Fax: Area Code: Phone Number:

Email:

What is the Best time to reach you? Choose One Days Evenings Nights

Dogs Name: Dogs Age:

Gender: Choose One Male Female

Height:

Weight:

Date Heartworm test given:

Current Location of Dog:

Color: Choose One Fawn Apricot Brindle

Neutered/Spayed: Choose One Neutered Spayed Intact

Shots UTD: Choose One Yes No

Rabies Shots Current: Choose One Yes No

Heart Worm Current: Choose One Yes No

Last time HW Med Given:

Brand of HW Med Given:

Fecal Test:

Brand of food dog gets:

How Much Each Feeding:

How many times per day is he/she fed?

Any chronic illnesses that the dog suffers and list medications they take for it?

Does the dog require any immediate medical treatment: Choose One Yes No

If yes, what for?

Is the dog housebroke?: Choose One Yes No

Is the dog good with children?: Choose One Under 5yrs 5-12 yrs 12-18yrs All Ages

Is the dog crate trained?: Choose One Yes No

Is the dog obedience trained?: Choose One Yes No

Reason for surrendering dog:

Is the dog good with other animals? (check all that apply):

Small Dogs

Large Dogs

Cats

Birds

Wildlife

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Has the dog ever bitten anyone?: Choose One Yes No

Describe Incident(s):

Has the dog ever show any aggression, violent, or inappropriate behavior?: Choose One Yes No

Describe :

Breeder's Name:

Kennel Name:

Kennel Address:

City: State: Zip Code:

Do you have AKC papers on this dog?: Choose One Yes No

What is your Veterinarian’s name/Clinic Name:

Address:

City: State: Zip Code:

Phone:

To submit your data press here: