Small Animal Surrender Questionnaire | Lawrence Humane Society

Pre-Relinquishment Questionnaire (Small Animal)
Please complete the following questionnaire in advance of your scheduled appointment to surrender.

The purpose of this form is to collect important information about your pet's behavioral and medical history. It is important that the answers provided are honest and detailed. The information you provide will help us make the pet feel safe and secure in our care and aid in finding the best outcome for the pet, including placement options and matchmaking for adoptions.

You should submit one form per pet you are requesting to surrender to Lawrence Humane Society.

Once you have submitted your questionnaire, a staff member will review the information and may contact you if any additional information is needed.

If you have any questions, please call the Pet Resource Center at 785-371-0473 or help@lawrencehumane.org.

Thank you!
Name:*

First Name of Owner or GuardianLast Name of Owner or Guardian
Preferred Name:
Name you wish to be called if different than above
Pronouns:

She/Her/HersHe/Him/HisThey/Them/TheirsOther
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:*
Please enter a valid phone number.
Alternate Phone:
Please enter a valid phone number.
Email:*
example@example.com
Preferred method of contact:*

PhoneEmail
Preferred time of contact:*

MorningAfternoonNo preference
Preferred language:*

EnglishSpanishOther
Have you used Lawrence Humane Society (LHS) services before or adopted a pet from LHS?*

YesNo

Other Information
Is there any other information you would like us to know about your pet that may help us find the best placement options for this animal?*

YesNo
Other information for best placement options:*

Agreement
I am the owner or authorized agent/designee for the owner of the animal described above.*

I agree
The information provided in this questionnaire is accurate and true to the best of my knowledge.*

I agree
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Pre-Relinquishment Questionnaire (Small Animal)