Surrendering Family Form

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Surrender a Westie

* Indicates required field

Family Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Work Phone *

Home Phone *

Cell Phone *

Dog's Name *

Dog's Nick Names *

Neutered/Spayed Information *

Yes No

Age *

Birth Date *

What is the reason why you are giving up your dog? *

For example, behavior issue, medical problem, financial expense, death or incapacitation of owner, business transfer, having to move, etc.)

DOG'S MEDICAL INFORMATION

Are your dog's Rabies shorts current? *

Yes No

If yes... *

1 year 3 year

DHLPP current? *

Yes No

Lyme Disease current? *

Yes No

Last Heartworm Test Date *

Last Fecal Check Date *

Allergies To What, If Known *

List Any Medications (What AND How Frequently Administered) *

Heartworm Medicine Brand Name *

Date last given *

Tick Medicine Brand Name *

Date last given *

Flea Medicine Brand Name *

Date last given *

CONTACT INFORMATION OF CURRENT VETERINARIAN

Business Name *

Veterinarian's Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

WESTIE'S DAILY ACTIVITY AND CARE

Dog Food? (Brand, How much fed, How often fed) *

House Trained? *

Yes No Mostly Never

Obedience Training? List of commands obeyed *

How frequently do you exercise your dog? (Walks, yard, ball play, etc.) *

Where does your Westie sleep during the day AND evening? *

Favorite Toys? *

Will you send the favorite toys with him or her? *

Yes No

Is your Westie frightened of anything such as baths, brush, fireworks, etc.? Please list *

Is your Westie good with children under 9 years of age? *

Yes No

Is your Westie good with older kids? *

Yes No

Is your Westie good with other dogs? *

Yes No

Is your Westie good with cats? *

Yes No

Does your Westie travel well in the car? *

Yes No

If NO, what is problem behavior? *

Has your Westie bitten anyone or any animal in the past 90 days? *

Yes No

If Yes, what were the conditions? *

Any Permanent ID such as microchip/tattoo or scars? *

Will you contact your current veterinarian to ask them to release a summary of the medical records to the Westie Rescue of Western PA? *

Yes No

In your experience with your Westie, what would be their best type of home? *

What additional training is required to make your Westie a better pet, if any? *

Is there any special medical care required for your Westie? *

Please list any additional information that will assist us in finding the right home for your Westie *

WHAT WORDS DO YOU USE FOR...

Go for a Walk *

Car Ride *

Go Potty *

Treats *

Play Time Activity (Ball, Teddy Bear, etc.) *

Wait *

Sit *

Food *

Please send the Westie Rescue of Western PA some digital images of your dog via email to
Coordinator, Bob Murphy, at westieman1948@yahoo.com

Submit

Home
About Us
Adopt/Surrender a Westie
Adoption List
Westie Facts
Behavior Training
Rescue Tails

Home
About Us
Adopt/Surrender A Westie
Up For Adoption
Adopted Westies
Westie Facts
Behavior Training
Rescue Tails
Events
Become a Rescuer
Become a Foster
Donate
Photos