Dog Surrender Questionnaire

Pixie is able to take owner-surrendered dogs as time and circumstances allow. Please provide as much information as you can about health and behavior. Filling out this form does not guarantee that Pixie is able to accept your dog into our adoption program, but we will be in contact within two days. (Pixie is closed to the public Sunday and Monday.)

Your Contact Information

Your Name (required)

Your Email (required)

Your Address (required, street + city + state + zipcode):

Telephone (required)

Tell us about your dog.

An astrick (*) indicates required fields.

Dog's Name*:

Age*:

Dog's Gender (M/F):

Breed*:

Is the dog up-to-date on shots/vaccines*?

Does the dog have any known health issues*? (if yes, explain below in "other")

Is the dog fixed?*

Where did you get the dog?*

How long have you had the dog?*

Reason for surrender?*

Timeline for surrender?*

How does the dog do with other dogs?*

How does the dog do when meeting new people?*

has the dog ever been around kids? Cats?*

Any other behavioral notes?

Other:




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    510 N.E. MLK Blvd.
    Portland, OR 97232

    Retail: (503) 542-3432
    Adoption: (503) 542-3433
    Fax: (503) 542-3437

    Hours:
    Tuesday-Friday 11:00 - 6:00
    Saturday 11:00 to 4:00