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)

    Can you receive/send text messages from this number?

    Tell us about your dog.

    An astrick (*) indicates required fields.

    Dog's Name*:


    Dog's Gender (M/F)*:

    Has this dog seen a vet*? (if yes, please list the clinic name/phone number):



    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?*

    Has the dog gone through formal training? If so, what was the training facility or trainer's name?*

    Any other behavioral notes?


  • Pixie social icons

    twitter facebook instagram

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

    Phone: (503) 542-3432
    Fax: (503) 542-3437

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