Pet Surrender Form

Pet Surrender Form

Please complete this form to request surrender of a pet to our rescue. Completing the form does not guarantee intake, and intake is at the rescue’s sole discretion.
Owner Information
Full Name

First NameMiddle NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Co-owner Information
Co-owner full name

First NameMiddle NameLast Name
Co-owner phone number
Please enter a valid phone number.Format: (000) 000-0000.
Co-owner email address
example@example.com
Pet Information
Pet name
Species
Breed
Color
Sex
Age (years)
Microchip status
Microchip number
Spay/neuter status
Where obtained
How long owned
Behavior and Bite History
Behavioral concerns

Other
Has the pet ever bitten a person or another animal?
Describe any aggressive or concerning behavior incidents
What triggers or situations lead to the behavior?
How often and how severe is the behavior?

1

2

3

4

5

6

7

8

9

10

1 is Rare / Mild, 10 is Frequent / Severe
Medical History
Medical history summary
Current medications
Vaccination status
Veterinary clinic name
Veterinary clinic phone
Please enter a valid phone number.Format: (000) 000-0000.
Veterinary clinic contact details
Household Information
Other pets in the home

Other
Children in the home
Housing type
Landlord permission to keep pets
Reason for Surrender
Primary reason for surrender

Other
Please explain the reason for surrender
Legal Surrender and Waiver
Legal Surrender and Waiver Acknowledgement
Signature
Date

MonthDayYear
Date
Should be Empty:

Pet Surrender Form

Owner Information

Co-owner Information

Pet Information

Behavior and Bite History

Medical History

Household Information

Reason for Surrender

Legal Surrender and Waiver