Animal Surrender Form
Harley Foster Haven
Name
*
First Name
Last Name
Phone
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ANIMAL & HOUSEHOLD INFORMATION
When do you need to surrender the animal?
*
Animal's Name
*
Sex
*
Male
Female
Age
*
Is the animal
*
Purebreed
Mix
Tail
*
Docked
Natural
How long have you had the animal?
*
Where did you 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
00 - 03
04 - 09
10 - 17
18 - 29
30 - 59
60 +
What other animals did the animal live with?
*
no other animals
dogs
cats
Other
BEHAVIOR
Your dogs usual behavior
How does the animal usually behave towards people they know?
*
Rows
never encounter
friendly
afraid
show teeth/growl
snaps
bites
other
men
women
children
How does the animal usually behave towards people they DO NOT know?
*
Rows
never encounter
friendly
afraid
show teeth/growl
snaps
bites
other
men
women
children
How does the animal usually behave towards animals they know?
*
Rows
never encounter
friendly
afraid
show teeth/growl
snaps
bites
other
dogs
cats
How does the animal usually behave towards animals they DO NOT know?
*
Rows
never encounter
friendly
afraid
show teeth/growl
snaps
bites
other
dogs
cats
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
will bite
Is the animal housetrained?
*
yes
no
partially
How does the animal let you know they need to go out?
*
Where does the animal spend the majority of their time?
*
inside the house, runs free
inside the house, crated
outside the house, runs free 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
crated
Other
When left alone, does animal usually show any of the following behaviors?
*
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
Other
What toys does the animal like?
*
balls
frisbee
plush
squeaky
tug toy
none
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 animals bad habits
*
Is the animal allowed on furniture?
*
yes
no
Where does the animal usually sleep at overnight?
*
crate
floor
your bed
couch
kids bed
dog bed
outside
Other
What commands does the animal know?
*
no commands known
sit
down
stay
come
leave it
place
heel
Other
Describe the animals leash skills
*
Describe the animals reaction if a person or other dog gets near or attempts to take food he is eating.
*
Describe the animals reaction if a person or other dog attempts to take a toy they are playing with.
*
Describe the animals reaction if a person or other dog attempts to take a bone or other treat they have
*
Describe the animals reaction if touched when sleeping.
*
Does the animal have problems riding in 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 BEHAVIOR
(behavior that has ever 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?
*
yes
no
If yes, please explain
Has the animal ever attacked or bit a 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 address and number.
*
Does the animal see a veterinarian at least once a year?
*
yes
no
Is the animal spayed/neutered?
*
yes
no
What vaccinations has the animal received?
*
rabies
dhhp
bordatella
none
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 behaviors when handled by a vet or groomer.
*
Rows
never done
shows teeth/growls
snap
bite
none of these
examine
restrain
administer shots
bathe
clean ears
trim nails
take blood
Does the animal have to be muzzled at the veterinarians?
*
yes
no
Does the animal have any past or present health problems?
*
yes
no
If yes, please describe
Is the animal currently taking any medication?
*
yes
no
If yes, please list medications
FEEDING
What type of food does the animal eat?
*
canned
dry
soft
table scraps
raw
home cooked
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 animal like?
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?
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a up close head shot of the animal?
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload any records you have for the animal?
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Save
Submit
Should be Empty: