Welcome to GPRM

Pre-Surrender Questions

Contact Information

First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
-

Email*

Home Phone*

Work Phone
x

Cell Phone

*=required

Dog's Name:*

Dog's Sex*

Is this dog spayed or neutered?*

Dog's Age: (Indicate if approximate or actual)*

Does the dog have AKC Papers?*

Yes

Dog's Description: Please describe the color and markings (white, white with grey badger face etc.)*

Does the dog have double dew claws:*

Yes	No
Unsure

Where did you obtain this dog?

Breeder	Other Rescue
Prior Owner	National Great Pyrenees Rescue (NGPR)
Pet Store	Shelter

If you selected "Other" above, please indicate how you obtained the dog.

How much did the dog cost? (If applicable)

Your reason(s) for surrendering the dog:*

We understand that no dog is perfect. Please answer the following questions as honestly and accurately as possible so that we may better help in placing this dog in the best possible environment. ----- Is the dog a:

House Dog	Outdoor Dog
Livestock Guardian Dog

Where does the dog spend the majority of its time?*

How long have you had the dog?*

Where does the dog sleep?*

How is the dog contained?

Chain	Invisible Fence
Roams (not contained)	Fence
Kennel	Trolley

If the dog is contained by a fence, please indicate height and type of fence:

Has the dog ever escaped or jumped a fence? (select all that apply)

Escaped through an open door	Jumped through a glass window
Tunneled under a fence	Jumped over a fence
Jumped through a screen window

If the dog has jumped a fence, please indicate height of fence and type of fence (stockade, picket, wire, electric etc.)

Will the dog run if loose?*

Yes	No
Unsure

Is the dog crate trained?*

Yes	No
Unsure

If the dog is crate trained, please indicate how often, how long, and the last time the dog used the crate:

Is the dog house trained?*

Yes	No
Unsure

Will the dog walk quietly on a leash?*

Yes	No
Unsure

Will the dog come when called? (select all that apply)

In the house only	Inside and Outside
Sometimes	Not at all

Does the dog get along safely with cats? (select all that apply)

Chases cats inside the house	Chases cats outside
Inside the house only	Ignores cats
Sleeps with cats	Yes
No	Unsure

Does the dog get along safely with other dogs? (select all that apply)

Female dogs only	Male dogs only
Large dogs only	Small dogs only
Yes	No
Unsure

Does the dog get along safely with children? (select all that apply)

Children over 12	Children over 6
Children under 6	Lives with children now
Yes	No
Unsure

Does the dog get along safely with strangers? (select all that apply)

No - reacts aggressively and lunges	No - growls
No - runs away	Yes - once they are introduced by me
Yes - greets strangers with a tail wag	Yes - will allow strangers to approach and pet/rub
Unsure

When food or treats are present, does the dog (select all that apply)

Allows other dogs near their food	Allows people to take food away
Is aggressive if another dog is in the room	Will growl or snap if a person attempts to touchthe food bowl
Allows other dogs within 6 feet of food	Is aggressive if another dog approaches
Will allow people to take treats/bones away	Will not allow people or other dogs to take treats/bones away
Will share their food and treats/bones with other dogs

What is the dog fed? Please indicate can or dry, brand (Purina ONE, Purina ProPlan, Alpo, whatever was left over from dinner etc.) and quantity and how often.*

Would you describe the dog as:

Sedentary	Slightly Active
Very Active

Is the dog destructive in the home (select all that apply)

No	Somewhat - will chew papers or tissue boxes
Very Destructive - Chews windows/doors/rugs etc	Sometimes Destructive - when left alone for over 2hours
Unsure	Yes

Please describe any destructive behaviors

Does the dog become anxious when left alone?*

Yes	No
Unsure

Please describe your dog's behavior when left alone (anxious if left in the home alone, anxious if tied outside and you leave, etc.)*

Is there any history of aggressive behavior toward people?*

Yes

If you answered yes, please describe the aggressive behavior

Is there any history of aggressive behavior with other animals?*

Yes

If you answered yes, please describe the aggressive behavior and type of animal involved

Please tell us everything you can about the dog's history, personality traits, training, quirks, etc.*

What is the current weight of your dog (in pounds)*

Please answer the following questions to the best of your ability. If you don't know the date of a vaccination or test, simply say "unsure" or "don't know" Does the dog have: (Select all that apply)

Addison's Disease	Diabetes
Environmental Allergies	Heartworm Disease
Lyme Disease	Skin Issues (hot spots)
Arthritis	Ehrlichiosis
Food Allergies	Hip or Leg Problems
Prone to Ear Infections

If you checked any of the above boxes, OR if your dog has a medical issue that is not listed, please explain.

Date of last DHLP vaccination and expiration date:*

Date of Last Rabies Vaccination and Expiration Date*

Date of last Bordetella vaccination and expiration date*

Date of last Lyme Vaccination and expiration date*

Date of last HeartWorm test

Date given and type of Heartworm Preventative (HeartGard, Ivermectin, Trifexis etc.)

Date Flea/Tick preventative last applied and type (K9 Advantix, Trifexis, Frontline etc.)

Date of Last fecal exam for worms and Date/Type of worming (if applicable)*

Veterinarian's Name:*

Veterinarian's Telephone Number*

Number of people in your household

Ages of Children living in the household

Do you currently own other dogs?*

Yes

If you have other dogs, please list: Breed, Age, Sex, and whether spayed or neutered

Do you currently own other pets? (cats, guinea pigs, birds, etc.) If so, please indicate type of animal, age, sex, and if spayed or neutered

By submission of this information, and my(our) initials in the following box, I(we) attest that the information provided on this application is true and accurate to the best of my(our) knowledge.*

*=required

Great Pyrenees Rescue Montana