* Required
Dog's Name
Dog's Birthdate
Exact or Approximate
If birthdate is approximate, please explain.
Is your dog spayed/neutered?
Description of Dog
* Is the dog a purebred or mixed breed? If mixed, what breeds?
How old was your dog when you acquired it?
Where did you acquire your dog from?
Name, address and phone number of breeder (if applicable)
If yes, company and chip #
Is your dog micro-chipped?
Information on most recent vaccinations (please email copies of vet records if available to [email protected])
Name of Primary Veterinarian
Address of Primary Veterinarian
Phone number of Primary Veterinarian
Vaccination/Treatment (Please enter date given and name of vet)
Annual Shots (e.g. DHLPP)
Rabies Vaccination
Bordatella (Kennel cough)
Last Heart-worm check
Is your dog on monthly heartworm preventative?
What kind of heartworm preventative is your dog on?
Date last heartworm preventative given.
Last flea/tick treatment (e.g. Frontline)
Does you dog have chronic ear infections?
Does your dog have hot spots/skin problems?
Does your dog have other health conditions? Please explain
Has your dog ever had a sudden injury or surgery other than being spayed/neutered? If so, please explain and list year
Vet name, address and phone number where injury was treated or surgery performed
What brand of dog food do you feed your dog?
How much do you feed your dog?
When, and how many times do you feed your dog per day?
Where does your dog sleep?
Where does your dog live/stay during the day or when humans are not home?
Does your dog...
have separation anxiety?
Attempt to run out of open doors from the home?
Jump fences?
Attempt to escape from a fence in any way?
If yes, explain how
Like to ride in a car?
Like to swim?
Allow you to take toys from them?
Chase cars?
Urinate when scared?
Come when called?
Growl at strangers?
Is your dog...
Crate trained?
Afraid of storms?
Afraid of men?
Currently living with children?
If yes, what age of the children?
Good with children?
Good with cats?
Good with other dogs?
Used to being groomed?
Used to being walked?
Good on a leash? (doesn't pull)
Obedience trained?
What commands does your dog know?
Has your dog ever bitten a human?
If yes, please explain
Has your dog ever been attacked by another dog?
If yes, please explain
What are your dog's best qualities?
What are your dog's worse qualities?
What does your dog enjoy? e.g. favorite toy, activity etc
What does your dog dislike? e.g. fears
Where do you feel would be an ideal home for your dog?
Is there any other information which you feel will be helpful for your dogs new home?
Why are you surrendering the dog?
ATTESTATION BY THE RELINQUISHING OWNER(S): I / We certify that I / we own the above dog and that this dog has not shown any signs of aggression, or bitten anyone in the past ten days and that the statements above are true and accurate. I / We agree to indemnify and hold harmless Adopt a Golden Nashville (AGN) by, from and against all claims, suits, damages, liabilities and costs related to or in any manner connected with this dog. I / We further acknowledge understanding that the dog becomes the property of AGN, and that they may place the dog, spay/neuter, or euthanize if in the best interest of the dog.
Date in which this form is being completed?
* Owner's name
Co-owner's name
* Email address
* Phone number
Secondary phone number
By submitting this application, I/we hereby certify that all information provided on this application is true, compete and accurate to the best of my/our knowledge. I/we attest that we have read the Terms and Conditions of Adoption and also understand that completion and submission of this application does not guarantee foster/adoption of a Golden Retriever. Adopt a Golden Nashville reserves the right to refuse any foster/adoption.
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