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Philadelphia Boxer Rescue (PBR, Inc.) Owner Surrender Form Response-O-Matic Form


Just complete this form. Click on Submit when ready to send.


Philadelphia Boxer Rescue encourages you to contact us. The more information you can provide, the easier it will be to help your boxer. 

Tell us how to get in touch with you:

Complete Address  

E-mail    (
Tel        (include area code)
FAX       (include area code)          
Please contact me as soon as possible regarding this matter.
How did you hear about Philadelphia Boxer Rescue? (choose one)

I have a:
What is your dog's name?:
Date of Birth:
Sex:  Male     Female
Color:    Fawn     Brindle White
Ears:    Natural    Cropped

Where did you get your dog:
When did you get your dog?

Is your dog spayed/neutered? Yes   No
Is your dog up to date on all shots (rabies and DHLPP)?
Yes   No
Was your dog heartworm tested last season?
Yes   No
On heartworm preventative last season?
Yes   No

Is your dog currently without medical problems? 
Yes   No
If no, please detail problems here: 

Is your dog:

Housebroken?   Yes    No        Crate trained? Yes    No
Yes   No                      Barker?   Yes   No

Is your dog good with:

Other dogs? Yes   No   Unsure       
Are there dogs in the current household? 
Yes   No
Please give breed, age and if they are spayed or neutered:
Yes   No   Unsure 
Are there cats in the current household? 
Yes   No
Please give breed, age and if they are spayed or neutered:
Children under 4?
Yes   No    Unsure 
Children over 4?
Yes   No   Unsure 
Are there children in the current household? 
Yes   No
Please give ages of children:

Has your dog ever bitten a human or another animal?   Yes   No
If yes, please describe what happened in detail:

Where does your dog stay during the day?
Where does your dog stay at night?
What brand of dog food is dog on?
How much does dog eat? (cups or cans)
Feeding habits

I am giving up my dog because:

Additional information we should know about your dog:

We will ask you additional questions and for clarification on these questions above, but this is to get us started.   Once you hit "submit" we will receive your form and contact you to discuss your dog possibly coming into our rescue.  Please remember that all rescues are not alike.  If you have questions about the placement of your dog, ask lots of questions and do not turn your dog over to anyone with whom you do not feel comfortable.  

Please hit send button, if you receive the "Thank you" page, it has been sucessfully submitted.