NAME(S):   

                                                    ADDRESS:   

                                                    City/State/Zip

                                                    Day Phone:  

                                                              Other Phone: 

                                                              Email:          

BASIC BOXER INFORMATION

                                                              Purebred?    Yes         No

                                                              Name of Boxer 

                                                              Age                  

                                                              Sex                   Male          Female 

                                                              Color            Fawn     Brindle     White

                                                              Spayed/Neutered?   Yes          No

                                                              Microchipped?      Yes        No

                                                              Vaccinations up-to-date?

                                                              Rabies       Yes         No

                                                              Distemper  Yes         No

                                                              Bordetella    Yes         No

                                                              Last date heartworm tested  

                                                              On preventative?  Yes      No

                                                              Name of Vet Clinic 

HOW YOU ACQUIRED YOUR BOXER (Required)

                                                              Purchased from Breeder   Yes       No

                                                              If Yes, Name of Breeder

                                                              Have you contacted them about returning the dog?    Yes        No

                                                              Purchased from Pet Store   Yes        No

                                                              If Yes, Name of Store    

                                                              Other source    

                                                              Is your Boxer registered?  Yes        No

                                                              How long have you owned your Boxer? 

MORE ABOUT YOUR BOXER

                                                              Good with children?      Yes     No     Don't know

                                                              Good with other dogs?     Yes     No     Don't know

                                                              Good with cats?     Yes     No     Don't know

                                                              Crate-trained?    Yes     No, never used crate

                                                              Any formal obedience training?  Yes, attended classes  No

                                                              Any medical problems?   

                                                              Any behavior problems? 

                                                              Has your Boxer ever bitten anyone?   Yes     No

                                                              If yes, explain circumstances 

                                                              Has your Boxer ever nipped at anyone?   Yes     No

                                                              If yes, explain circumstances 

                                                                             Has your Boxer ever growled/snapped at anyone?  Yes     No

                                                              If yes, explain circumstances 

                                                                              Any other information we should know about your Boxer?

REASONS FOR SURRENDER

                                                              Are you sure you want to surrender your Boxer?  Yes, positive      Not sure

                                                              Are you interested in receiving counseling to help you keep your Boxer?  Yes      No

                                                              What is the reason for surrender?

                                                              Is there a date you must surrender the dog by? 

                                                              Have you contacted anyone else about surrendering your dog? List name(s)

Please provide an answer to every question in order to receive a response. You will be contacted via email - if you do not receive a response within 2 days, please send an email message to vicki@boxerrebound.com  Frequently messages from us are returned as undeliverable when servers or software will not accept email from unknown senders.