Surrender Form

Midwest Vizsla Rescue
Release of Owned Vizslas to Rescue
BILL OF TRANSFER AND PROFILE INFORMATION

I understand that my dog must be up to date on all vaccinations and have a current Heartworm test with a negative result *

YES

I, *

First

Last

Email *

hereby relinquish all ownership rights to this Vizsla, known as *

First

Last

SEX OF DOG *

Male Female

AGE *

To Midwest Vizsla Rescue as of this date *

Dog's Date Of Birth *

Breeder, if known *

Picture Of Dog *

Max file size: 20MB

TEMPERAMENT: Can You Add Anything To Describe The Dog's General Temperament? (For example: friendly, reserved, lethargic, anxious to please, outgoing, cautious, timid, very trainable, untrainable, adaptable, obedient, stubborn, enthusiastic, protective, calm) *

Does The Dog Follow Commands? (sit, stay, come, down, fetch, give) *

Does The Dog Know Any Other Commands? *

What are the dog's worst issues? How Is The Dog With Thunder & Lightning? Nail trims? *

Has The Dog Been Hunted Over? *

Yes No

Is The Dog Crate Trained? *

Yes No

Describe The Dog's Personality *

Has The Dog Ever Bitten, Growled or Snapped At Anyone? *

Yes No

If Yes, Explain *

Has The Dog Ever Killed Another Animal? *

Yes No

If Yes, Explain *

Does The Dog Travel Well In The Car? *

Yes No

Does The Dog Live Inside Or Outside? *

Where Does The Dog Sleep? *

This Vizsla Has The Following Known Physical, Medical and/or Temperamental Problems: *

Color: *

Weight *

Tail Docked? *

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Rabies Due: *

Parvo Vaccine Date: *

DHLPP Vaccine Date: *

Date of Last Heartworm Test *

Heartworm Test *

Positive Negative

Is This Dog On Heartworm Prevention Med? *

Yes No

If Your Vizsla Needs Vaccination or Heartworm Updates, Are You Willing To Have That Done Before The Vizsla Is Surrendered? *

Yes No

Has The Dog Ever Had His/Her Toenails Clipped? *

Yes No

Has The Dog Ever Had His/Her Ears Cleaned? *

Yes No

Is The Dog Microchipped or Tattooed for Identification? Company/Number *

Please Describe as Necessary *

Brand of Food & Feeding Schedule and Amount *

Current Medication and Dose *

Has The Dog Ever Shown Food Aggression? *

Yes No

Is There Anything Else About This Dog The New Owners Should Know? *

Reason for Surrendering Your Dog? *

Are You Willing To Donate To Midwest Vizsla Rescue To Help Defray The Costs Involved In Rescue and Finding A Good, Safe and Loving Home for Your Dog? If Yes, How Much? *

Is Your Dog Spayed/Neutered? *

Yes No

NOTE: Owner released dogs placed in rescue must be spayed/neutered, current on all shots and heartworm tests unless other arrangements are made.

MVR evaluates the dog prior to placement (per ACFA regulations). If a suitable home is not found locally (Kansas and Missouri) we contact other VCA rescue coordinators in Nebraska, Iowa, Oklahoma and Arkansas for suitable applications. Each dog is placed with the understanding that if the placement should not work out, the dog is returned to our rescue program and NOT re-homed unless we are part of the process. If you have any questions about our program please ask.

I (WE) declare that I (WE) are the legal and sole owner(s) and that there are no encumbrances to my (OUR) title to this Vizsla. I (WE) give permission for Midwest Rescue to obtain records on the above named Vizsla from the dog's veterinarian.

By signing below, it is understood that all rights of ownership to said dog are relinquished to Midwest Vizsla Rescue.

Signature: Date:

Print Name

Address:

Phone: (work:) (home/cell:)

Comment *

Submit

Midwest Vizsla RescueRelease of Owned Vizslas to RescueBILL OF TRANSFER AND PROFILE INFORMATION

Midwest Vizsla Rescue
Release of Owned Vizslas to Rescue
BILL OF TRANSFER AND PROFILE INFORMATION