First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Cell Phone*

Alt Email

Text/Pager Email

What county do you live in? (if you live in the U.S.)*

How did you hear about us?

PLEASE PROVIDE AS MUCH INFORMATION AS IS KNOWN ON YOUR PET

Name of Dog?*

Sex of Dog*
Choose one: Female Male

Date of Birth of Pet or estimate if not known.*

When did you originally acquire this dog? (Give your best estimate if you're not sure.)*

How did you originally acquire this dog?*
Choose one: Breeder Shelter Another Rescue Friend/family Craigslist or other community listing Other

Please provide the name of the breeder, kennel, shelter or rescue that the dog was acquired from.*

Type of Breed
Choose one: American Hairless Terrier Chinese Crested Hairless Chinese Crested Powder Puff Other Xolo

What breed is the pet your surrendering if not the breeds listed above?*

Please list any physical attributes/features.*

What color is the dog?*

Size (Small up to 10 pounds; Medium 11-15 pounds; Large over 16 pounds)*
Choose one: Small Medium Large

What color eyes?*
Choose one: Blue Brown One blue, one brown

Any other markings you would like to make note of?*

Is the dog spayed/neutered?*
Choose one: Yes No N/A

If yes, date of spay/neuter. Put N/A if not altered.*

Dog's Current Situation

Please indicate if dog likes.

Please indicate if dog dislikes.

Temperament of the dog.

Please select any habits/issues the dog may have.

Has the dog ever bitten a person?*
Choose one: Yes No N/A

If yes, please explain. If no, put N/A.*

Has the dog ever attacked or killed another animal?*
Choose one: Yes No N/A

If yes, please explain. If no, put N/A*

MEDICAL HISTORY (Please provide copies of medical history, if possible):

Please supply the name, address and phone number of your veterinarian:*

Heartworm test date:*

Results of heartworm test?*
Choose one: Negative Positive Never tested

Has the dog had their rabies shot?*
Choose one: Yes No N/A

If yes, please supply date of last rabies shot. If the dog as never had one put N/A.*

Please list any other vaccines the dog has had that you are aware of. Including the kind and date it was given. *

Please tell us if the dog has any other medical concerns,illnesses, allergies, and injuries (past&present).*

Is the dog on any current medication?*
Choose one: Yes No N/A

If yes, please list all medication and dosage.*

What type of food is the dog currently eating? How many feedings per day? The amount at each feeding?*

Reason for releasing animal to rescue?*

Grace Period: There is a grace period of three (3) days should the owners/releasers change their mind and wish to reclaim the above-mentioned dog. If the dog is reclaimed, there will be a boarding fee of no less than $15.00 per day, plus any veterinary expenses and any additional expenses incurred during the course of the dogs stay with Bald is Beautiful Hairless and Small Breed Rescue. If you wish to waive your rights to the three (3) day grace period, please sign directly below. By signing below, it is hereafter understood that all rights of ownership to said dog are relinquished to Bald is Beautiful Hairless and Small Breed Rescue. Microchip: Owner further agrees to the transfer of the microchip information to Bald is Beautiful Hairless and Small Breed Rescue and/or its assigns. Attorney Fees and Costs: Should it become necessary for Bald is Beautiful Hairless and Small Breed Rescue to take legal action to defend itself or otherwise enforce the provisions of this Agreement, the undersigned owner/releaser agrees to pay all court costs and reasonable attorney fees. The place of venue shall be Greenville County SC. Please initial that you understand this statement:*

I certify that the information entered on this form is true. Enter your name and date*