Owner Release Information
Date ______________________
Dog's Name: ______________________________ Breed: Cocker Spaniel ________
Color ___________________________________ Sex ___________ Age ________
Your careful and honest answers will aid us immeasurably in determining the best possible future for your dog. If the dog has not been exposed to question, please leave it blank.
1. Has the dog been primarily an indoor or outdoor dog? (circle one) Indoor / outdoor / both
2. Has the dog been chained in the yard? Yes / No
3. Does the dog stay by him/herself in the house for extended periods of time? Yes / No
4. Can the dog stay by him/herself in a fenced yard for extended periods of time? Yes / No
If not, why? _________________________________________________________
5. Has the dog received any formal obedience training? Yes / No
6. Is the dog allowed to be at the dinner table while humans are eating? Yes / No
7. Is the dog accustomed to using a doggie door? Yes / No
8. Is the dog allowed on the furniture? Yes / No
9. Is the dog allowed to play roughly with humans? Yes / No
10. Does the dog fight with other dogs? Yes / No
11. Has the dog ever bitten a human? Yes / No
If yes, under what circumstances? ______________________________________________
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12. Has the dog ever killed or injured another animal? Yes / No -- If Yes, circle all that apply: Dog / Cat / Livestock / Poultry
13. Where does the dog sleep ? ____________________________________________
14. Does the dog do any of the following: (Circle all that apply) -- Climb Fences / Jump Fences (approx. height ____________ ) Dig / Roam / Tear/Chew Furniture/ Chase Livestock / React to people in uniform / Ride well in cars / Dump trash cans / Tear up the garden / Chase moving vehicles (cars, bicycles, motorcycles) / Scratch at the door to get in or out
15. In your absence, where is the dog kept? Indoors / Outdoors
16. Does the dog like children? Yes / No -- If yes, list age group: ________________________ If no, list age group: ________________________
17. Is the dog protective of the home and family? Yes / No
18. Has the dog ever suffered a serious illness? Yes / No If Yes, please explain ____________
__________________________________________________________________________
19. Has any surgical procedure been performed on the dog? Yes / No If yes, please explain:
__________________________________________________________________________
20. Has the dog had any fractured bones? Yes / No If yes -- which ones? _________________
21. Does the dog suffer from any allergies (eg. grass, plants, fleas, food?) Yes / No
If yes, please explain _______________________________________________________
22. Is the dog on any medications? Yes / No -- If yes, please explain: ____________________
23. Does the dog suffer from separation anxiety? Y / N
24. Is the dog housebroken? Yes / No If yes, how does the dog let you know it needs to go out?
__________________________________________________________________________
25. Where was the dog obtained? Circle One -- Animal Shelter / Other Party / Breeder
(name of breeder _______________________)
If breeder, was the breeder notified that you could no longer keep the dog? Y / N
26. Who is the dog's veterinarian? _______________________________________________
27. Brand of dog food fed to the dog? ____________________________________________
Time(s) and amount dog is fed _______________________________________________
28. Has the dog ever been bred? Yes / No
29. Has the dog ever been kenneled? Yes / No
30. Is the dog spayed/neutered? Yes / No
31. Is the dog up to date on vaccinations? Yes / No
32. Is the dog microchipped? Yes / No
33. Does the dog have a regular/professional groomer? If so, who? _____________________
34. Is the dog crate trained? Yes / No
35. Is the dog food aggressive? Yes / No
36. Does the dog get along with cats? Yes / No
37. Is there any special problem that we should understand concerning this dog that will enable
us to place him/her most appropriately? ________________________________________
______________________________________________________________________
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38. Are there any other comments you would like to make concerning this dog?
________________________________________________________________
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39. What is the reason that you are relinquishing this dog?
________________________________________________________________
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40. May we contact you if we have more questions about the dog? Y / N
This information is true and correct to the best of my knowledge:
Signed: ______________________________________________________
Date: ________________________________________________________
Print Name: ___________________________________________________
Address: _____________________________________________________
City: __________________________________ State: _________________
Home Phone: ____________________ Work Phone: ___________________
Email address:__________________________________________________