EmailMe Form - Owner Surrender Questionnaire

OWNER INFORMATION

YOUR FULL NAME *

Must place your full name

EMAIL ADDRESS *

VALID PHONE NUMBER *

CURRENT HOME ADDRESS *

Street Address

CITY, STATE ZIP *

YOUR DATE OF BIRTH *

DRIVERS LICENSE# *

PET'S INFORMATION

TYPE OF PET *

Puppy (6 months and younger)

Dog (7 months and older)

PET'S NAME *

PET'S BREED *

PET'S AGE *

PET'S COLOR *

PET PHOTO: Please include photo *

(jpg,jpeg,png)

PET'S SEX *

Male

Female

SPAYED/NEUTERED *

Spayed (Female)

Neutered (Male)

Neither

PET VACCINATED *

Yes

No

Unsure

within last year

PET HEARTWORM TEST *

Yes

No

Unsure

within last year

INSERT THE VETERINARIAN SERVICES YOU USE BELOW *

IF YOUR PET IS NOT SPAYED, DO YOU KNOW IF YOUR PET IS CURRENTLY PREGNANT? *

Yes

No

Unsure

Does not apply

IF YOUR PET RECENTLY HAD A LITTER, ARE THEY STILL NURSING?

Yes

No

Unsure

Does not apply

IF YOUR PET WAS PREGNANT AND GAVE BIRTH, HOW MANY PUPPIES WERE IN THE LITTER?
(If not applicable, type N/A)

HOW OLD ARE THE PUPPIES IN THE LITTER?
(If not applicable, type N/A)

WHERE DID YOU GET THE DOG FROM?

HOW LONG HAVE YOU OWNED THE DOG?

Additional Information:

HAS YOUR PET SHOWN ANY SIGNS OF THE FOLLOWING BEHAVIORAL ISSUES? *

IF OTHER (Please explain)
If you checked a box indicating your pet shows a behavioral issue, please provide an explain:

WHAT IS YOUR DOG’S BEHAVIOR LIKE WITH MEN, WOMEN, CHILDREN, AND STRANGERS? *

WHAT IS YOUR DOG’S BEHAVIOR LIKE WITH OTHER DOGS, CATS, OR LIVESTOCK? *

DOES YOUR DOG LIVE WITH OTHER ANIMALS? *

Yes

No

HAS YOUR DOG BEEN INTRODUCED TO OTHER ANIMALS OUTSIDE OF THE HOUSEHOLD? *

Yes

No

HAS YOUR DOG EVER KILLED OR INJURED ANOTHER ANIMAL? *

Yes

No

IF YES (Please explain)

HAS YOUR DOG EVER CHASED OR ATTEMPTED TO ATTACK OR BITE A PERSON? *

Yes

No

IF YES (Please explain)

HAS YOUR DOG EVER BITTEN A PERSON? *

Yes

No

IF YES (Please explain)

HAS YOUR DOG EVER SERIOUSLY INJURED OR KILLED A PERSON? *

Yes

No

IF YES (Please explain)

HAS THE DOG PREVIOUSLY BEEN DESIGNATED A NUISANCE, DANGEROUS, OR VICIOUS DOG? *

Yes

No

IF YES, please indicate the designation that was assigned, the date of the designation, and the county or city/state in which the designation was made:

WHAT IS YOUR REASON FOR SURRENDERING? *

By signing my name below, I am acknowledging that I have answered the questions provided on this questionnaire to the best of my knowledge.

Clear

SIGNATURE REQUIRED