Pre-Relinquishment Questionnaire (Dog) | Lawrence Humane Society

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

The purpose of this form is to collect vital 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 contact 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
Are you the legal owner of the animal you wish to surrender?*

YesNo
If no, please explain.*

Dog Information
Dog Name:*
Breed:*
In unknown, please indicate size (small / med / large / x-large)
Age and/or Birthday:*
Estimate if unsure
Weight:*
Estimate if unsure
Sex:*

Male - neuteredFemale - spayedMale - intactFemale - intactUnknown
Color(s):*
Distinguishing Markings:
How long have you had your dog?*

Behavior Around Other Animal Types (Small Animals, Livestock, Wildlife)
Has your dog ever reacted to other animal types by growling, showing teeth, snapping, or biting?*

Yes, livestockYes, small pets (hamster, guinea pig, etc.)Yes, wildlife (squirrels, etc.)No, my dog has never reacted to other animals as described
Describe the circumstance(s) that caused your dog to react negatively. Please include the species of animal reacted to in each instance.
If the circumstance(s) resulted in a bite, injury, or death, please describe the severity of injuries inflicted, if any:
Does your dog usually chase or attempt to chase outdoor cats, squirrels, or other small animals?*

YesNoUnknown

Other Information
Please tell us something interesting, unique or fun about your dog, his/her traits, or personality that we can tell potential adopters:
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:

Photo of Pet
Please upload a photo of your pet.

We would like to use the photo to help market your pet. A horizontal photo is preferred.
Cancelof

Euthanasia
The Lawrence Humane Society strives to find positive outcomes for each animal that enters the shelter, however there are some instances where we may elect to euthanize an animal. Reasons include but are not limited to severe medical conditions that cannot be effectively treated or managed, or unsafe behavior.
I understand my pet may be euthanized if deemed appropriate by the Lawrence Humane Society staff.*

I agree
Would you like to be notified if the animal you are surrendering is at risk of euthanasia?*

Yes, I would like to be notified.No, I do not wish to be notified.
I understand that the Lawrence Humane Society does NOT guarantee to provide notification prior to euthanasia, even if I indicated above that I would like to be contacted.*

I agree

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: