Basset and Beagle Rescue of the Heartland Relinquishment Form

Your Contact Info Name:
Address: City: State: Zipcode:
Phone (preferred): Type:

Please Describe your dog Dog's Name:   Age: Breed:

Vet's Name:   Vet's Phone:
Is your Dog... Up-to-date on Shots?   YesNo
Altered?   YesNo
On Heartworm Preventative?   YesNo
Housetrained?   YesNo
Crate trained?   YesNo

Has your dog ever bitten anyone?   YesNo

Which of the following does your dog do well with... Kids Cats Other Dogs

Which of the following has your dog lived with... Kids Cats Other Dogs

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