Pet Relinquish Form

Pet Relinquish Formaear12018-03-16T12:46:08-05:00

Pet Relinquish

Current Owner Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Main Phone #*
Alternate Phone #
Please select the type of animal are surrendering*
- Dog
- Cat
- Rabbit
This Pet is*
If "other" please explain*
By what date must you surrender the pet?
Surrender Reason*
Pet Information
*
Breed Sex - M/F/Unknown Coloring Weight Age Spayed/Neutered Y/N
Vet Information
Vet's Name
Phone
City
State
Medical Information
Is the animal up to date on vaccines? If so which ones?*
Health Issues*
Please check all that apply and use the box below to explain any of the conditions you checked.
- No known Health Issues
- Allergies
- Dietary Issues
- Orthopedic Issues - Hip dysplasia, arthritis, stiffness, or other issues
- Ear problems
- Reoccurring Infections of any kind
- Seizures
- Skin Problems
- Past Surgeries
- Other Medical Issues
Please explain any of the health issues you checked above and anything else you can tell us with regard to the medical history of the pet
Personality Profile of the Pet
Has your pet ever bitten a person or another animal?*
- Yes
- No
If Yes, please explain*
Is the dog/cat good with -
Check all that apply, if unsure do not check
- Other Dogs
- Cats
- Small animals
- Young Children
- Children
Is the dog housebroken?*
- Yes
- No
Is the dog crate trained?*
- Yes
- No
Behavior Issues?*
Check all that apply
- No known behaviour issues
- Accidents in the house
- Guarding food/toys
- Aggression towards other animals
- Aggression towards strangers
- Doesn't like to be left alone
- Destructive Habits
Please provide an explanation of any of the behaviour issues checked above or others not on the list
Comments
Please tell us any other information you would like to convey with regard to the pet you are surrenduring
How did you hear about us?*

Breed	Sex - M/F/Unknown	Coloring	Weight	Age	Spayed/Neutered Y/N

Pet Relinquish Form

Pet Relinquish

Current Owner Information

Pet Information

Vet Information

Medical Information

Personality Profile of the Pet