Animal Surrender Form
Name
*
First Name
Last Name
Phone
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State
Post Code
ANIMAL & HOUSEHOLD INFORMATION
When do you need to surrender the Cat/Dog?
*
Animal Name
*
Gender
*
Male
Female
Age
*
Is the Animal
*
Purebreed
Mix
How long have you owned the Animal?
*
Where did you originally get the Animal?
*
Why are you surrendering the Animal?
*
Including yourself, how many people of the following ages live in your home?
*
Rows
FEMALE
MALE
OTHER
00 - 03
04 - 09
10 - 17
18 - 29
30 - 59
60 +
What other animals did the Cat/Dog live with?
*
no other animals
dogs
cats
Other
BEHAVIOUR
Your animal's usual behaviour
How does the Animal usually behave towards people they know?
*
Rows
never encounter
friendly
afraid
show teeth/growl/hiss
bites/scratches
other
men
women
children
How does the Animal usually behave towards people they DO NOT know?
*
Rows
never encounter
friendly
afraid
show teeth/growl/hiss
bites/scratches
other
men
women
children
How does the Animal usually behave towards animals they know?
*
Rows
never encounter
friendly
afraid
show teeth/growl/hiss
bites/scratches
other
dogs
cats
How does the Animal usually behave towards animals they DO NOT know?
*
Rows
never encounter
friendly
afraid
show teeth/growl/hiss
bites/scratches
other
dogs
cats
Any further comments on answers above
How does the Animal usually react when an unfamiliar person approaches or enters the yard or house?
*
friendly
afraid
barks
shows teeth/growls/hiss
will bite/scratch
Other
Is the Animal housetrained?
*
yes
no
partially
How does the Dog let you know they need to go outside? (Write N/A for cats)
*
Where does the Animal spend the majority of their time?
*
inside the house
inside the house crated
outside the house in yard
outside the house kennel
outside the house tied up
Other
How many hours a day is the Animal left alone without a human?
*
never
1-3 hours
4-8 hours
9-12 hours
over 12 hours
When left alone, is he/she...
*
outdoors
free roam in home
confined to a room in home
crated
Other
When left alone, does Animal usually show any of the following behaviours?
*
destroy household items
urinate/defecate
bark
cry
none of these
Other
When the Animal plays, do they typically...
*
jumps
growls
barks
bites lightly
bites hard
none of these
Claws/Scratches
hisses
Other
What toys does the Animal like?
*
balls
frisbee
plush
squeaky
tug toy
none
scratching items (for cats)
string (for cats)
Other
What games does the Animal like?
*
fetch
tug
chase
wrestling
none
Other
Is the Animal scared of anything
*
yes
no
If yes, please explain
Please tell us the Animal/s bad habit/s (if unknown or nil write N/A)
*
Is the Animal allowed on furniture?
*
yes
no
Where does the Animal usually sleep at night?
*
crate
floor
your bed
couch
kids bed
dog/cat bed
outside
Other
What commands does the Animal know?
*
no commands known
sit
down
stay
come
leave it
place
heel
Other
Describe the Animal's leash walking skills.
*
Describe the Animal's reaction if a person or other cat/dog gets near or attempts to take food they are eating.
*
Describe the Animal's reaction if a person or other dog/cat attempts to take a toy they are playing with.
*
Describe the Animal's reaction if a person or other dog/cat attempts to take a bone or other treat they have.
*
Describe the Animal's reaction if touched when sleeping.
*
Does the Animal have problems travelling in a car?
*
yes
no
don't know
If yes, please explain -
Has the Animal escaped your property 2 or more times in the last 6 months?
*
yes
no
If yes, please explain -
AGGRESSIVE BEHAVIOUR
(behaviour that has happened)
Has the Animal ever attacked or bit a person?
*
yes
no
If yes, please explain -
Has the Animal ever attacked or bit another dog/cat?
*
yes
no
If yes, please explain -
Has the Animal ever attacked or bit farm animals? (chickens, horses, cows, goat, pig, sheep, etc...)
*
yes
no
If yes, please explain -
MEDICAL
Please list all veterinarians that have seen the Animal, including their Clinic Name, address and number.
*
Does the Animal see a veterinarian at least once a year?
*
yes
no
Is the Animal spayed/neutered?
*
yes
no
Are vaccinations current?
*
yes
no
Has the Animal been tested for heartworm?
*
yes
no
If yes, what were test results -
Is the Animal taking heartworm preventative?
*
yes
no
If yes, when is the next dosage due?
Is the Animal microchipped?
*
yes
no
Check if the Animal has ever shown any of the following behaviours when handled by a vet or groomer.
*
Rows
never done
shows teeth/growls/hiss
bite/scratch
none of these
examine
restrain
administer vaccination
bathe
clean ears
trim nails
take blood
Does the Animal have to be muzzled/restrained at the veterinarians?
*
yes
no
Does the Animal have any past or present health problems?
*
yes
no
If yes, please detail -
Is the Animal currently taking any medication?
*
yes
no
If yes, please list medication/s -
FEEDING
What type of food does the Animal eat?
*
canned
dry
soft
table scraps
raw
home cooked
Other
How many times a day is Animal fed?
*
1 time
2 times
3 times
free feeds
How much is fed per feeding?
*
1 cup
1 1/2 cup
2 cups
2 1/2 cups
not sure, just fill the bowl up
Other
Does the Animal get treats?
*
yes
no
If yes, what treats does the Animal enjoy?
OTHER
Please feel free to tell us any other information about the Animal you feel is important.
*
Please upload a full body picture of the Animal
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Please upload an up close head photo of the Animal
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Please upload any records you have for the Animal (Vet Certs/Microchip Ownership etc.)
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