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Surrender Application
Dog's Name
Breed
Age
Weight in Lbs
Dog's Date of Birth
Sex of the Dog
Male
Female
Neutered / Spayed
Yes
No
Microchipped
Yes
No
How long have you owned?
Where did you aquire the dog?
Receiving heartworm prevention?
Yes
No
Manufacturer / Brand(s)
Date of last prevention received
Receiving flea protection?
Yes
No
Manufacturer / Brand(s)
Date of last prevention received
Receiving tick protection?
Yes
No
Manufacturer /Brand(s)
Date of last prevention received
Has your dog ever been treated for:
Eye Infections
Heartworms
Ear Infections
Skin Infections
Kidney Issues
Heart Issues
Cancer
Urinary Tract Infections
None of the above
Something Else
Brand of food currently receiving
Please detail your answer to the above
Please list any other medical issues diagnosed by a vet
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