Small Animal Surrender Form

Pet's name

Pet's Age

Species

Color/Markings

Pet's Sex

Spayed/Neutered

Microchipped? Microchipped? Yes No

If yes; microchip number

Surgery tattoo? If “yes”; where?

How long have you had your pet?

Owner Name

Owner Address

Email

Phone

Why are you surrendering?

If the reason is behavioral or medical, please explain any actions you have taken to try to resolve the issue

Is there anything our organization can do that may help you keep your pet?

Where did you get your pet from?

If a breeder or rescue, what is the name and location of the person/organization?

Have you attempted to return your pet to where you got it from? Have you attempted to return your pet to where you got it from? Yes No

If “yes”, what was the reason that they did not take it?

Have you contacted any rescue groups to try to re-home your pet? Have you contacted any rescue groups to try to re-home your pet? Yes No

If “yes”, what was the reason they did not take your pet?

Where does your pet spend their time? Where does your pet spend their time? Indoors Outdoors Both

If both, how much time is spent outside?

What type/brand of pet litter does your pet like?

Does your pet like to be pet or held? How do they react to being handled?

Is your pet litterbox trained? Is your pet litterbox trained? Yes No

Has your pet ever bitten a person? If “yes” please explain and include whether the person had to be treated by a doctor

How is your pet around children?

Has your pet ever bitten another animal? If “yes” please explain

How is your pet around cats?

How is your pet around strangers?

How is your pet around dogs?

How is your pet at the Veterinarian?

What is the name of your Veterinarian?

Has your pet ever needed to be sedated for an exam?

Is your pet current on vaccines?

Has your pet had any medical concerns?

Does your pet take any medications?

What food does your pet eat?

A shelter environment can be more stressful for a pet used to living in a home. Therefore, they have a better chance at finding a home if adopters knows what to expect. Please tell us more about your pet at home (examples: are they more playful or relaxed? Where do they like to sleep? Are they affectionate or independent?)

If during their first 7 days in our care, we find your pet to be unable to be adopted out due to a behavior or medical concern, would you be willing to redeem them?

I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in this application may render me civilly liable. I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in this application may render me civilly liable. Yes, I have answered to the best of my ability

Please type your full name and date as your electronic signature