Animal Surrender Information
Your Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of animal/s being surrendered:
Age:
Sex:
Breed / Colour:
Vet Details (Name / Address):
Brief Description: personality, characteristics, special requirements etc:
Usual/preferred Litter and tray type
Usual/preferred food type and schedule
Usual/preferred place to sleep
How is the animal around:
Dogs:
Cats:
Children:
Has the pet any medical issues or received any vet treatment? (other than usual, vaccination, neuter, flea / worm etc) We are a non-profit animal rescue, therefore should we find that you have been dishonest, you may be liable for any costs incurred in relation to the treatment required.
Has the animal ever attacked / bitten /scratched a human or animal? If so, please describe. Again, we require complete honesty!
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Is the animal Vaccinated (with card)?
YES
NO
Neutered?
YES
NO
Microchip Number
Last flea & worm treated:
Email: roxiesrescue1@gmail.com Tell: 07592722033 Facebook: @Roxiesrescue
Should be Empty: