Owner Surrender Request

What species is your pet?

What is your pet's age?

What is your pet's name?

Please upload a recent photo of your pet?

Where did you obtain your pet?

Is your pet up-to-date on all vaccinations?

Please upload a copy of your pet's medical records

Is your pet heart worm positive?

What (if any) health issues does your pet have?

*Does your pet receive monthly heart worm prevention?

What (if any) other medications does your dog take on a regular basis?

Is your pet aggressive toward cats?

Is your pet aggressive toward dogs?

Is your pet aggressive toward children?

Is your pet aggressive toward humans?

Has your pet ever attacked/killed another animal?

Has your pet ever bitten a human?

Is your pet house-trained?

Does your pet suffer from separation anxiety?

Is your pet leash trained?

Please write a short bio for your pet.

What food is your pet accustom to eating?

Where is your pet accustom to sleeping?

What toys/treats does your pet usually enjoy?

Why are you requesting to surrender your pet?

I hereby certify that I am the rightful owner/keeper/caretaker/custodian of the animal who is/are the subject of
this Animal Surrender Form, hereinafter referred to as “the animal.” I hereby surrender any and all property
rights to the animal. I certify that no other person has a right of property to the animal. I understand that by
surrendering my property rights to the animal, the animal may be transferred into the custody of an animal
shelter. I also hereby certify that the animal has not bitten or scratched a human or another animal within the
past 10 days. I understand that once I relinquish the animal, the animal will not be available to be returned. I
further certify that I have read and understand the terms of this Animal Surrender Form.