Northcoast Doberman Rescue Surrender Application
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First Name
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Last Name
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Address
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City
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State
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Postal Code
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Primary Phone Number
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Secondary Phone Number
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Email Address
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Pet's Name
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Sex
Male
Female
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Pet's Age
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Pet's Weight (lbs)
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Breed
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Color
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Is pet spayed/neutered?
Yes
No
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Is your dog up to date on vaccinations?
Yes
No
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Has your dog been vaccinated against bordatella (kennel cough)?
Yes
No
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Are vet records available?
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Date dog was last seen by veterinarian?
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Vet's Name/Clinic
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Vet's phone number
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Any known medical issues?
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How and When did you aquire your dog?
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Is the dog housebroken?
Yes
No
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Does the dog have seperation anxiety?
Yes
No
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Does the dog have a chewing problem?
Yes
No
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If yes please elaborate on the chewing problem:
0/255 characters
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Does the dog have a bite record?
Yes
No
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If the dog has a bite record, please explain:
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Does the dog have aggression towards people?
Yes
No
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Does the dog have aggression towards children?
Yes
No
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Does the dog get along well with other dogs:
Yes
No
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Does the dog get along with cats?
Yes
No
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Reason you are surrendering the dog?
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Does the pet need to be out of your house by a certain date?
Yes
No
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If yes please specify date?
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