Copyright. Luv A Chin Rescue. All rights reserved.

Owner's First and Last Name:

Address: 


City/State/Zip Code: 


Phone Number: 


Email Address:  


What is the reason for surrendering your dog? 


Dog's Name:  


Sex of Dog? Male or Female?


Is your dog spayed or neutered? 


Color – Please type the best color to describe your dog here:

  • Black and White

  • Sable or Red and White

  • Lemon and White

  • Tri Colored (Black, White and Brown/red)

  • Other


If other, please describe:


Dog’s Approximate Weight:  


Dog's Age:  


Dog's Date of Birth (if known):  


Where was your Japanese Chin obtained? Pet Store, Breeder, Craigslist, Human Society or Animal Shelter, Craigslist, Rescue (please describe below), Other?


If other or Rescue, please explain/please let us know what rescue group: 

Current Vet Clinic's Name:  


Current Vet Clinic's Phone Number:  


Is your dog up to date on vaccinations? 


Does your dog have any ongoing or previous medical issues? 

​For example: allergies, ear infections, skin infections, etc. Please be as truthful and objective as possible. Luv A Chin Rescue takes in many dogs with medical issues. It is important that we know as much information as possible in order to place your dog in a foster home that is best suited to meet his needs.

​​

If you responded yes to medical issues, please describe medical issue(s) below along with any medications your dog is currently taking. Again, please be as truthful and objective as possible:


Is your dog microchipped?


If yes, provide number here:


If your dog housebroken?


If no or partial housebroken, please explain:  


Is your dog crate/kennel trained?


Is your dog leash trained? 


Obedience Trained? For example, knows sit, stay, come, heel, fetch, down, drop it, roll over, other? Please type all that apply here:


Does your dog like or tolerate - Please see list below and let us know what your dog has been exposed to and doesn't mind and/or ignores. Please type all that apply here:

  • Men

  • Women

  • Kids (toddler/infants)

  • Kids (young)

  • Kids (teen)

  • Small Dogs

  • Medium Dogs

  • Big Dogs

  • Female Dogs

  • Male Dogs

  • Birds

  • Cats

  • Other small animals? - If yes, please specify in the space below 


Other small animals? Please specify: 

 

Does your dog's dislike - Please see list below and let us know what your dog has been exposed to and dislikes or is aggressive towards. Please type all that apply here:

  • Men

  • Women

  • Kids (toddler/infants)

  • Kids (young)

  • Kids (teen)

  • Small Dogs

  • Medium Dogs

  • Big Dogs

  • Female Dogs

  • Male Dogs

  • Cats

  • Birds

  • Cats

  • Other small animals?

  • No Dislikes


Other small animals? Please specify:  

 

Has your dog EVER bitten?

Please be as truthful and objective as possible. Luv A Chin Rescue takes in dogs with bite histories. It is important that we know as much information as possible in order to place a dog in the best foster home best suited to meet his needs. 

 

If Yes, How many times?

Again, please be as truthful and objective as possible.  

 

If yes to Bite History, Please see list below and type all that apply here: 

  • Adult (Human)

  • Child (Human) - If yes,

  • please provide age(s) in space below

  • Cat

  • Dog - If yes, please provide breed(s) in space below


Bite History, type of aggression – please specify as asked above: 

 

If yes to Bite History, see below options. Please rate the worst bite here:

It is extremely important that you be as truthful and objective as possible.

  • Snap only - no teeth contact with skin (grumpy, poor behavior, posturing)

  • Light bite - no serious bruising, minor skin damage (scrapes), no punctures

  • Serious bite - determined bite, puncture wounds and/or severe bruising

  • Extreme Bite - bites requiring medical care/attention, serious punctures and/or severe bruising

  • Other injury – please describe below

 

If yes to other injury, please describe the other injury:
 

 

If yes to Bite History, Please explain the incident(s) in as much detail as possible here: 

It is extremely important that you be as truthful and objective as possible:  


Has your dog ever shown signs of food aggression? 

For example: dog growls or snaps when someone/something comes near him/her when eating.

 

Has your dog ever shown signs of resource guarding?

For example: dog growls or snaps when someone/something comes near him when he has a toy, sitting on owners lap, etc.

 

If yes to resource guarding, Please briefly describe:  

 

Does your dog have any destructive habits to self or other objects? 

If yes, please briefly describe:  

 

Does your dog have any other behavioral issues not previously discussed in this questionnaire? 
For example: Anxiety, separation anxiety, depression, etc. 


If yes to other behavioral issues, please briefly describe:

 

What brand of food does your dog currently eat? 


How much food do you feed your dog per day and how often?

For example: 1 cup, 2 times a day (morning and night).

 

Where does your dog typically sleep at night? 

 

Does your dog have any history of extreme breathing difficulty when in a stressful situation, such as meeting strangers and/or traveling in the car?

 

If yes to breathing difficulties, please describe: 

 

Tell us how long your dog is used to riding in a car: See below options and please type the most accurate here:

We need this information because your dog may have to be transported to a foster home several hours away from where you live. Please pick the best choice that describes how long your dog is used to riding in a
car.

  • Has ridden in a car for long trips or several hours

  • Has ridden in a car for short trips of less than one hour

  • Has never ridden in a car 


How does your dog do riding in a car?

Please see below options and let us know which one is most accurate. Also use the space below to tell us more about how he rides in a car such as: gets car sick, gets overly excited and anxious, goes to sleep, has to look out the window to see all that is going on, barks the entire time.

  • Loves it!

  • Hates it!

  • Does OK for short trips

  • Don’t know, he has never been in a car

 

When riding in a car, how does your dog usually travel?

  • Loose in the car seat

  • In a crate or kennel

  • In a doggy car seat

  • In the seat with a doggy seat belt

  • I’m not sure

 

Please email 3 photos of your dog to info@luvachinrescue.org along with this Surrender Questionnaire.

Luv A Chin Rescue cannot accept a dog without a photo. Different angles of the dog's body and face are preferred to confirm that the dog is a Japanese Chin. 


Surrender Questionnaire

Please copy and paste this form into an email or word document and email back to info@luvachinrescue.org

Please fill this form out with as much detail as possible!

Please complete this questionnaire as honestly and thoroughly as possible. Your responses will help determine if specific skills or health experience is needed to accommodate your dog in a foster home. If you have any specific questions about the surrender process, please let us know and we will do our best to answer any questions you may have. A volunteer will contact you within 24 hours after submission of this form.  


Luv A Chin Rescue

rESCUING, rehabilitating, AND REHOMING jAPANESE cHINS in need!