EmailMeForm
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?
*
Aggression
Resource guarding
Excessive barking
Mouthing/biting
None
Other
IF OTHER (Please explain)
DOES YOUR PET HAVE A BITE HISTORY?
*
Yes
No
IF YES (Please 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?
*
HAS YOUR DOG LIVED 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)
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
