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This form must be filled out complete and with as much detail as possible.  The text boxes have no limitation to the amount you enter.
If you have more than 1 pet to relinquish, please complete separate forms for each pet.
What is the reason for Surrendering Your Pet?
Note:  If the reason is due to medical admission, please CLICK HERE to complete the medical release form, then please come back and complete this Pet Intake Information Form

   
Your Name
Spouse's Name, if appl.
Address
City, State, Zip
Home Phone
Cell Phone
Work Phone
Email Address
   
Name of Pet
Type of Pet (Dog, Cat, Bird, etc.)
Breed
DOB or Approx. Age
Weight
Gender
Spayed / Neutered
Distinguishing Markings
Tattoo/Chip
If Yes, please provide the Chip ID and Mfg of Chip
Is this pet house trained?
Is this pet crate trained?
How long have you owned this pet?
If you are not the original owner, please provide us the last known contact info of the previous owner Name:

Phone:

Up to date on Vaccinations
Date of last vet visit
Reason for vet visit
Vet / Clinic Information Name:

Full Address:

Phone Number:

What is the preferred brand of food?
How much do you feed?
Times fed per day:
Preferred place to eat:
Where does this pet stay during the day?
Where does this pet sleep at night?
How often and what kind of exercise does this pet enjoy?
Please list all medical conditions, including accidents or injuries:
Please list all repetitive medical conditions (Rashes, Ear Infections, Stones, Etc.)
Please list all unusual habits or behaviors (eats rocks, jumps wall, counter surf, etc.)
   
Please respond to the following statements pertaining to this pet's behavior:

What is your pet's behavior ...

... around men?
... around women?
... around children (and what age)?
... around male dogs?
... around female dogs?
... around puppies?
... around cats?
... around other animals (specify)?
... when eating? (food guarding?)
... when playing with toys (toy guarding?)
... when going on walks?
... when going for a car ride?
... when getting groomed? (nail clipping, bathing, hair trimming, etc.)
   
Does this pet respond to his/her name?
Does this pet use a Doggie Door?
Has this pet had obedience training?
Has this pet ever had aggressive behavior?
If yes, please explain:
Has this pet ever bitten anyone?
If yes, please explain who was bitten and the situation around that incident:
Is this pet destructive when left alone?
If yes, please describe:
Does this pet have any fears?
If yes, please explain:
   
Personality Traits
(Please check all that applies)
 
  Outgoing / Friendly

  Playful

  Swimmer

  Runs through house

  Allowed on Furniture

  Prefers Crating

  Shy / Timid

  Excessive Barking

  Jumps Fences

  Jumps on People

  Digging

  Chews Anything

  Counter Surfing

  Uses Scratching Post (Cat)

  Scratches Furniture (Cat)

  Hides Under Beds (Cat or Dog)

  Prefers to be out of cage (Bird)

  Squawking When Cover is On (Bird)

  Flies Through the House (Bird)

 
   
This pet prefers to lay on/in ...  
  Laps

  Floor

Carpet

Tile

  Pet Bed

  People Bed

  Pillows

  Kennel / Crate

  Cage

 


To Validate Human entry of this form, please answer the following question:

Is the picture below a dog, cat, or fish?






DISCLAIMER:

  By submitting this form electronically, I/we certify legal ownership of this animal. I/We agree to surrender all rights of ownership of the animal listed herein to “Those Left Behind” Foundation. I/We also agree that any outstanding veterinarian bills related to animal listed herein prior to surrender, is the sole responsibility of surrendering family. I/We certify being of legal age (over 21).