First Name*
Last Name*
Address
City
State/Province
Zip/Postal Code -
Email*
Home Phone
Work Phone x
Cell Phone
Text/Pager Email
What is the name of the Animal you wish to surrender?*
Age*
Sex* Choose one: Male Female
Species?* Choose one: Dog Cat
Breed*
Is the animal spayed or neutered* Choose one: Yes No
Approximate Weight?*
If so, what is the microchip number or tatto?
Is the animal licensed? If so, in whose name and with what municipality?*
Who is listed as the legal owner on the veterinary records?*
Why are you surrendering this animal?*
If we could help you resolve the issue, would you be interested in keeping the animal?* Choose one: Yes No
Can you foster until we find a forever home?* Choose one: Yes No
Is there a deadline or date in which you need to have the animal placed in foster or rehomed by and if so, when?*
How long have you had the animal?*
How many homes, including yours, has the animal had?*
Where did you acquire the animal?*
Has this been an indoor pet?
Is the animal housebroken/litter box trained?
Has there been any history of aggression, biting, growling? If yes, please explain.*
To consider accepting the surrender, we will need to contact your veterinarian to get a copy of your pet's medical records. Please call your veterinarian and give permission for us to obtain those records. (All information will be kept confidential and your name will not be released to the new pet owners if adopted. Veterinarian's Name and Contact Information:*
Please list all vaccines the animal has been given and the date they were received*
Have there been any known surgeries? If so, what?
Are there any medical issues, conditions or treatments for the animal?
Has the animal bee diagnosed or treated for any of the following? Check all that apply
Do you use heartworm, flea and or tick prevention? If yes, please indicate the type and date it was last given.*
Choose all that the animal does well with
How would you describe your pet's personality?
How does your pet like to play?
What do you think would be an ideal home for your pet?
Does your pet exhibit any of the following behaviors?
What other things can you tell us about your pet's behavior or temperament that would help us to match them to a suitable home?
What is your feeding schedule?
What type of food (and brand) is your pet accustomed to eating?
If this pet is a dog, what percent of obedience would you say your pet is at? Choose one: 100% of the time More than 50% of the time Less than 50% of the time Not trained at all
Please check the obedience command that your dog will obey
Is the dog leash trained? Choose one: Yes No
How does your dog signal that they need to go out?
