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
Select One
Male
Female
Spayed / Neutered
Select One
Yes
No
Distinguishing Markings
Tattoo/Chip
Select One
Yes
No
If Yes, please provide
the Chip ID and Mfg of Chip
Is this pet house trained?
Select One
Yes
No
Is this pet crate trained?
Select One
Yes
No
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
Select One
Yes
No
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?
Select One
Yes
No
Does this pet use a Doggie Door?
Select One
Yes
No
Has this pet had obedience training?
Select One
Yes
No
Has this pet ever had aggressive behavior?
Select One
Yes
No
If yes, please explain:
Has this pet ever bitten anyone?
Select One
Yes
No
If yes, please explain who was bitten and the
situation around that incident:
Is this pet destructive when left alone?
Select One
Yes
No
If yes, please describe:
Does this pet have any
fears?
Select One
Yes
No
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
