Surrender Questionnaire

Please answer the following questions to the best of your knowledge. The more information we have on your pug, the better we can match it with a foster home and potential adoptive home.

Step 1 of 3

SECTION 1: ABOUT YOU
Legal Owner's Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code

SECTION 2: ABOUT YOUR PUG
Your Pug's Name
Is your dog a purebred Pug or a mix?*
Male or Female?*
Spayed or Neutered?*
If intact, are you willing to have your pug spayed or neutered?*
Dog's Age*
Dog's Date of Birth*
MM slash DD slash YYYY
Is your pug current on all vaccinations?*
DO YOU HAVE A CURRENTLY VALID RABIES VACCINATION CERTIFICATE?*
WHEN DOES RABIES VACCINATION CERTIFICATE EXPIRE?*
MM slash DD slash YYYY
Is your pug on Heartworm preventative?*
When was your pug last tested for Heartworm?
MM slash DD slash YYYY
Does your pug have a microchip?*
Where did you get your pug from and how long have you had him/her?*
EXACTLY where do you keep the pug when you are not home? Please be specific, i.e., loose outside, outside in a kennel, indoors free, indoors in a crate, in the laundry room, etc.*
Is this an indoor or an outside pug?*
EXACTLY where does your pug sleep at night?*
Is your pug reliably housebroken?*
Does your pug mark in the house?*
Is your pug crate trained?*
Has your pug ever been left loose in the house while no one was home?*
Does your pug panic when left alone (i.e., barking, pawing at blinds or under doorways, scratching on doors, escaping, vocalizing and otherwise manifesting high [separation] anxiety)?*
Has your pug had ANY formal (obedience) training/classes?*
If yes, where, when and with whom?*
Is your pug well socialized (i.e., FREQUENTLY taken OFF its home property and exposed to strangers, strange dogs, strange things and public places?*
Does your pug walk well on a leash or does he/she pull?*
Has your pug been exposed to the following? How does your pug get along with each? If your pug has had exposure, please elaborate on how he/she behaves with each:
Kids
Toddlers (4 and under)
Cats
Other Dogs
If you had to use TWO of the following words ONLY, how would you describe your pug?*
- Submissive
- Dominant
- Affectionate
- Aggressive
- Fearful
- Confident
- Skittish/Shy
- Nervous/Neurotic
Does your pug bolt, jump or escape often?*
Does your pug have any health issues we should be aware of, including allergies?*
If yes, please explain*
Is your pug on any medications?*
If yes, please explain*
Was your pug ever diagnosed with or treated for Valley Fever?*
If yes, please explain*
Does your pug have arthritis?*
Does your pug have any behavioral issues, such as food aggression?*
If yes, please explain*
Has your pug ever bitten anyone?*
Has your pug ever attacked another dog?*
Has your pug lived in a home with a swimming pool?*
Does your pug know how to swim?*
Does your pug show a preference for either men or women?*
Why are you surrendering your pug?*
How much longer can you keep your pug while we locate a suitable foster home?*
What does your pug eat, and how much?*
What is the name, address and phone number of your pug's veterinarian?
What is the date (month and year) of your pug's last vet visit and the reason for the visit?*