Dog/Puppy Owner Surrender Request

This form will be sent to the Newnan-Coweta Humane Society Dog Team for review. We have the right to accept or refuse the dog(s) mentioned in the submission. Please note: There will be a surrender fee per dog accepted into NCHS.

Name of Dog
What breed is this dog? *
Approximately how old is this dog? *
If there is more than one dog being surrended, please list names, ages, and description of additional dogs.
Reason for surrendering *
How long have you had this dog? *
Please upload a picture of the animal(s) being surrendered *
Where did you get this dog? *
If adopted from a rescue or shelter, what is the name of the Rescue or Shelter?
What veterinarians have treated this dog? *
If yes, what conditions? What medications are being used?
Do you have vet records for: *	Spay/Neuter Microchip Rabies Vaccinations Heartworm Test w/ results Heartworm Test without results No Records No Vaccinations/Spay/Neuter/Heartworm Test
May we contact this veterinary office?
Is the dog on flea and/or Heartworm preventatives? *
Does this dog have any known medical conditions? *
Is the dog house/potty trained? *
Where does this dog live? *
Where does the dog sleep at night?
Has the dog lived with any of the following? *	Other dogs Cats Birds Other animals Children 0-3 years old Children 4-8 years old Children 9-12 years old Children over 12 years old None of the above
Describe the dog’s behavior, habits, and personality. Please include how this dog reacts to other dogs encountered outside of your home like on a walk. *
Has this dog ever snapped or bitten? *
If your dog has snapped/bitten, when and why did this occur?
What does this dog eat and at what time of day? (eg. wet food, dry food, brand of food) *
What else should we know about this dog?
Owner's First Name *
Owner's Last Name *
Owner's Preferred Contact Number *
Owner's Preferred Email Address *
Owner's Physical Address *