Surrender - Safe With Us Animal Rescue

Owner information

Lets gather a bit of information about you

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Contact permission *

After your pet is surrendered, may we contact you?

Animal information

And now, we want to know a bit of information about the animal.

Name *

Date of Birth

Age

Animal type *

Dog, Cat, etc

Breed *

Gender *

Description *

Color, size etc

Animal Medical

Lets gather some medical data.

Is the animal microchipped? *

Microchip company

Microchip number *

Is the animal spayed or neutered? *

Date

When was this done?

Last rabies vaccination date? *

Last heartworm test date? *

Heartworm results

Heartworm prevention

Brand and date of the last prevention administered

Flea and tick prevention

Brand and date of the last flea / tick prevention administrered

Medical history

Please list any past medical history and the treatment (skin problems, heartworms, eye issues, allergies, surgery, etc.)

Veterinarian information

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Animal information

We’d like to learn more about your animal and their history

How long have you had the animal? *

Food *

What kind of food, how much and what frequency?

Where did you get the animal?

Energy level *

Low
Medium
High

Housebroken

Crate trained

Commands known

Sit
Stay
Place
Down
Off
Heel
Come

What commands does the animal know

Other commands?

Trainer visits? *

Has the animal met with a trainer, or taken any classes?

Training details

What kind of training was undertaken? How successful was it?

Favorite activities *

What are their favorite activities to do?

Likes and Dislikes *

What do they like, and dislike?

Daytime

Where do you keep the animal during the day?

Night time

Where does the animal sleep at night?

Behavioral issues *

Aggression, anxiety, excessive barking, etc

Exposure to children?

Has the animal been exposed to children? If so, what ages, and what was the experience?

Exposure to dogs?

How is the animal around dogs?

Exposure to cats / small animals?

How is the animal around cats and other small animals?

Surrender details

Lets learn more about why the animal is being surrendered

Has the animal bitten or scratched a person in the last ten days? *

When, where and who did they bite/scratch?

What date, location and who?

What happened?

In your own words, let us know what happened?

Has the animal *ever* bitten someone?

Beyond the last ten days – has the animal ever bitten anyone?

When?

Was animal control involved?

Was skin broken?

What happened?

In your own words, describe the incident

Surrendering *

Why are you surrendering the animal?

Can we help you keep the animal? *

If we can help resolve issues with your animal, would you be interested in keeping it?

What would it take to help you keep the animal?

Would additional training or resources help you to keep the animal?

Further information

Is there any other information we’ve missed, that would be useful to a foster or adopter?

Owner information

Animal information

Animal Medical

Veterinarian information

Animal information

Surrender details

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