Surrender Form (No Payment)

Phone

This field is for validation purposes and should be left unchanged.

Name of dog(Required)

Sex(Required)

Colour(Required)

Microchip number

Microchip form signed?(Required)

Inoculation record?(Required)

Neutered / Spayed?(Required)

Date of neutering or last season(Required)

Date last wormed(Required)

Date of last flea treatment(Required)

Any medical conditions?

Medications supplied

Reason(s) for surrender

Surrender declaration

I am the owner of or have the authority to surrender to Pointer Rescue Service the animal described above. I hereby relinquish all rights of ownership. I also authorise the release of any veterinary records regarding the animal.

I certify that to the best of my knowledge I have disclosed all information about the animal concerning health, behaviour, history and anything else that may affect the safe placement of the animal in a new home and that all statements made above are true and correct. Failure to disclose accurate information will cause issues; due to the dangerous dogs act and the requirements of charities working with dogs not to pass on dangerous dogs, a dog when professionally assessed by a registered vet and deemed as dangerous will be put to sleep with no recourse to you.

Your name(Required)

Title First name Surname

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Digital Signature

I declare that the information submitted is accurate and complete. I understand that my electronic signature serves as my legally binding confirmation.

Date(Required)