Surrendering YOUR Westie

Sometimes in life things happen we can not control.
Regardless of our efforts to hold onto the things we
love, we must do what is best for all involved.
Sometimes that means relinquishing your
pet to a rescue.

Westie Rescue of Missouri is here to help make that
transition easier. Our trained volunteers are not
there to judge you, we are simply there to help you.
All our homes are pre-approved, pre-inspected
and vet referenced.

We interview our homes via email and telephone to assure the best possible placement for our Westies. Therefore, if you have come to that place in your life where you can no longer care for the needs of your Westie(s), for whatever reason, please call, email or fill out and submit the form below. The nearest representative will contact you within 24-72 hours.

Whatever you do - please don't take your Westie to a shelter.
He deserves so much more than that.

Please email Westie Rescue of Missouri today. A volunteer
will be in contact with you shortly.

Please fill out this Intake Questionnaire and click "submit" when completed.

Name
Address
Email
Telephone
I certify that I am the legal owner of (Enter Dog's Name Here) a Male or Female West Highland White Terrier, age ,date of birth . I have owned this dog for years.
This dog is is not current on its vaccinations and rabies shots. I hereby consent to Westie Rescue contacting my vet at to obtain any additional information concerning this dog's medical care.
The the best of my knowledge, this dog suffers from the following physical problems: This dog is on the following medicine: (Please list all Names of medicine, dosage and times per day medication is taken)
The dogs last vet visit was on . Vet records are provided with this release. Yes No
This dog is is not altered.
This dog has had the following additional surgeries:
This dog is is not housebroken. What words are used to tell the dog to go potty? How frequently is the dog let out?
What is the procedure?
How does the dog let you know that it needs to go out?
This dog is is not crate trained.
This dog does does not get along well with other dogs.
This dog does does not like cats.
This dog does does not like children.
This dog is accustomed to being alone hours a day. This dog does does not have problems being left alone. Describe problems:
When the dog is left alone it is crated allowed to run loose in the house .
This dog is fed dog food times a day.
In my opinion, the best kind of home for this dog would be:
The dog has the following personality traits: (check all that apply)
Runs away (Bolts if door is opened)	Friendly
Barks excessively	Digs excessively
Food aggressive	Toy aggressive
Active	Calm
Hyper (never sits down)	Shy around people
Kisser	Prefers men
Prefers women	Dog Fetches
Other:
Personality Comments:
Has dog bitten/attempted to bite anyone? Yes No
If yes, explain
(Westie Rescue does not usually take dogs that bite, however there are a few exceptions.)

Is the dog destructive in any way? Yes No
If yes, explain

Release
I hereby certify that I am the owner of this dog, free and clear of all other interests and I grant sole ownership of said dog to Westie Rescue of Missouri. I certify that the information that I am giving to Westie Rescue of Missouri, Inc. is accurate and that Westie Rescue of Missouri, Inc. or its agents will not be held liable or chargeable for any false information, or any misrepresentations that I have submitted on this form. I hereby forever release, discharge and agree to hold harmless Westie Rescue of Missouri, Inc. and its agents from all claims, demands, actions, causes of action, or liability of any kind whatsoever arising as a result of or in connection with the adoption or other disposition of the above named dog. I understand that I give up all rights and ownership and that this is a legally binding contract and cannot be rescinded. I certify that this dog is not possessed of any danger or vicious propensities and has never bitten or attempted to bite any person or animal, and that I have not willfully concealed information about the dog that might indicate such propensities. I have read the above and understand that by executing this document, I hereby surrender all rights and claims to the animal aforementioned. I further agree that ownership of this dog may be transferred to a new owner without further approval or contact with me. A SURRENDER DONATION TO HELP DEFRAY RESCUE EXPENSES WOULD BE GREATLY APPRECIATED. DONTATIONS ARE TAX DEDUCTIBLE. My donation to help this rescue effort is $ . (Checks payable : Westie Rescue of Missouri 2224 Evergreen Avenue Des Moines IA 50320