Owner Surrender Form
Carolina Animal Network
Owner Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Please describe in detail why you are surrendering your animal.
*
Animal's Basic Information
Animal Name
*
Species
*
Dog
Cat
Approximate Age/Birthdate
*
Animal's Breed (if known)
Description of animal (color, any specific markings etc.)
My animal is a...
*
Male
Female
Is the animal neutered/spayed?
*
Yes
No
Weight (in pounds)
How long have you owned this pet?
*
Does your pet live indoors or outdoors?
*
Animal Behavior
Has your animal ever bitten a person or another animal? If so, please specify the circumstances, what animal they bit and what the outcome was (any harm caused to person or other animal). If your pet has not bitten anyone to your knowledge, please type N/A.
*
Please list any major or minor behavior problems your pet exhibits: (ex. food aggression, digging, house soiling, barking too much, chewing/scratching things up, etc.)
Are there any other animals in your home? If so, what kind and how many?
Is your animal good with dogs?
*
Yes
No
Sometimes
Don't know, he/she has never been around dogs
Is your animal good with cats?
*
Yes
No
Sometimes
Don't know, he/she has never been around cats
Does this animal like children?
*
Yes
No
Don't know, he/she has never been around children
If you answered "No" to any of the questions above (is your animal good with dogs, cats and children), please explain
How does your pet respond to strangers or visitors? If you do not know, please enter N/A.
Please check the box if your animal is...
Housebroken/Litter Box trained
Crate trained
Can be left alone inside without incident
Good on the leash
Animal Health Information
If you have vet records for your animal, we will ask that you email them directly to us.
When was your animal's last veterinary appointment?
*
What vet are you currently using? Please list the name of the vet's office and location.
Is your animal up to date on these vaccinations? Check all that apply (if you know).
Rabies
Bordetella
Distemper/Parvo
FVRCP
Animal's heartworm status
*
Heartworm Positive
Heartworm Negative
Don't know
Is your animal on monthly heartworm prevention?
*
Yes
No
Does your animal have any health problems that you are aware of? If so, please explain.
If there is any other information you think we should know about your animal, please let us know below.
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