Animal Surrender Form
By signing this form, I state that I am the owner of the animal who is subject of this Animal Surrender Form, hereinafter referred to as "the animal." To my knowledge, no other person has any right to this animal. I hereby surrender all rights to the animal. I understand that once I relinquish the animal, he animal will not be available to be returned. I have read and understand the terms of this Animal Surrender Form
Owner Information
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Animal Information
Name
*
Animal Type
*
Weight/Size
*
Sex
*
Age
*
Gender
*
How long have you had the animal?
*
Months
*
Years
Where did you get this animal?
*
Friend/Family
Shelter/Rescue
Breeder
Pet Store
Other
If other, please explain
*
Spayed/Neutered?
*
Indoor/Outdoor
*
Color
*
Last Vet Visit
*
Current Vet
*
Please describe in detail why you are surrendering this pet
*
Behavior History
Does your animal live with other dogs
*
Yes
No
If yes, how do they interact and get along
*
Does your animal live with cats
*
Yes
No
If yes, how do they interact and get along
*
Does your dog live with kids
*
Yes
No
If yes, how do they interact and get along
*
Is there anything you want a new family to know about your animals interaction with
*
Is there anything you want a new family to know about your animals interaction with
Men
Women
Children
Dogs
Cats
Strangers
Other
Please tell us about your dog's "bad habits" or fears (chewing shoes, jumping on counters or people, hiding during thunderstorms etc.)
*
Does anything make your animal nervous
*
Are there any wonderful, special traits or habits that you would like the new family to know about
*
Household History
Do you take your animal outside to go to the bathroom
*
Yes
No
If yes, how many times a day does the dog go out
*
How does the dog let you know it needs to go outside
*
Does the animal have accidents in the house
*
Yes
No
If yes, how often
*
Daily
A few times a week
A few times a month
A few times a year
If yes, does your dog
*
Urinate
Defecate
Both
Is the animal crate trained
*
Yes
No
If yes, how long did the dog spend in a crate each day
*
How long can your dog "hold it"
*
Not at all
1-3 hours
4-8 hours
8-12 hours
12+ hours
How long is your dog left alone
*
Never
1-3 hours
4-8 hours
8-12 hours
12+ hours
When alone, is your dog
*
Outdoors
Free in the house
Confined to a room
Crated
Other
If other, please explain
*
When left alone does your dog
*
Destroy housebold item
Urinate
Defecate
Bark
Cry
None
Other
If other, please explain
*
If your dog destroys household furniture items, check all that aply
*
Chews Windows/Doors
Chews Furniture
Chews Clothing/Shoes
Chews Toys
Other
If other, please explain
*
When you are home, does the dog
*
Destroy household items
Urinate
Defecate
Bark
Cry
None
Other
If other, please explain
*
How does your dog react to bathing/handling such as petting or hugging
*
Are there areas on the dog's body your dog does not like to be touched
*
When touched in the above places, how does your dog respond
*
Moves away
Shows teeth
Growls
Snaps
Bites
No reaction
Is your dog permitted to sit/sleep on the furniture
*
Yes
No
How does your dog behave in the car
*
Fine in a crate/restraint
Never tried
Enjoys
Afraid
Resists entering
Sleeps
Barks
Vomits
Urinates/Defecates
Other
If other, please explain
*
What are your dogs favorite kind of toys
*
How does your dog react when you or another member of the family.....
*
Never tried
No reaction
Allows
Lunges
Shows Teeth
Growls
Snaps
Bites
Stops Behavior
Pet or touch the bowl of food while eating
pet or touch a bone, rawhide, pigs ear or other delicious edible while chewing
pet or touch a stolen food item
pet or touch a stolen object
pet or touch a toy in their mouth
pet or touch or move them while sleeping
push or pull them off furniture
approach them while next to another family member
Medical History and Behavior Towards the Veterinarian
Has your dog ever had surgey
*
Yes
No
If yes, please explain
*
Is your dog on a prescription diet or any medication
*
Yes
No
If yes, please explain
*
How does your dog behave during visits to the vet
*
Does your dog have to be muzzled at the vet
*
Yes
No
Is there anything else we should know about your dog's medical history
*
I am the owner of this animal or the owner's representative acting upon the owner's consent
*
Printed Name
*
Signature
*
Date
-
Month
-
Day
Year
Date
Submit
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