Are you the owner of the animal that is needing to be surrendered? *
Yes
No
Describe why you are filling out the surrender form on behalf of the owner
Your First Name
Your Surname
Your Phone Number
Owner's First Name *
Owner's Last Name *
Phone Number *
Email Address *
Street Address *
Suburb *
Postcode *
What is the reason for needing to surrender your animal? *
Name of animal *
Species of animal *
Alpaca
Bird
Cat
Chicken
Dog
Duck
Echidna
Goose
Guinea Pig
Kangaroo
Lizard
Other
Possum
Poultry
Rabbit
Reptile
Rodent
Rooster
Snake
Wombat
Breed/s *
Age (approximate) or Date of Birth *
Sex *
Female
Male
Is your animal desexed? *
Yes
No
Is your animal microchipped? *
Yes
No
Please provide the microchip number
How long (approximately) have you had this animal? *
Describe how this animal first entered your care (e.g. from a breeder, friend, gumtree etc.) *
Has your animal been vaccinated within the last 12 months? *
Yes
No
Please attach a copy of the most recent vaccination certificate (within the last 12 months)
does your animal like travelling in a car *
Does your animal have a regular Vet? *
Yes
No
What is the name of their regular Vet?
Has or does your animal have any medical issues, allergies or had any surgery? *
Yes
No
Describe the medical issues, allergies or previous surgeries
Is your animal on any ongoing medications? *
Yes
No
Describe what these ongoing medications are and how they need to be given (e.g. orally, with food, in the morning etc.)
Is your animal allowed inside your house? *
Never
Yes, free access all the time
Only when someone is home
Depends on the weather
Where is your animal kept during the day? *
Totally inside your house - no free access to outdoors
Inside your house with a flap or free access to outdoors
Inside your house until they asked to go out
Totally outdoor - no access to house
Confined to a shed, garage or other
Where is your animal kept during the night? *
Totally inside your house
Inside your house with a flap or free access to outdoors
Totally outdoor - no access to house
Confined to a shed, garage or other
Is your animal toilet trained? *
Yes
No
On average, how many hours is your animal left alone? *
Describe the type of exercise that your animal gets, and how often *
How does your animal behave/react to being groomed? *
Describe how your animal behaves when visiting the vet *
How does your animal behave around children? *
Has your animal ever lived with any other animals? *
Yes
No
Please describe the species of animal that your dog has lived with (e.g. dogs, cats etc.) as well as each of their ages (during the time that your dog lived with them), whether they were male or female and their breeds
Can your animal be left alone without human company? *
Yes
No
Describe what happens if your animal is left alone without human company
Does your animal need the company of another animal? *
Yes
No
Describe what animal/s
Has your animal ever shown aggression toward people? *
Yes
No
Please describe
Has your animal ever shown aggression to any other animals? *
Yes
No
Please describe
Is your animal destructive? *
Yes
No
Describe what your animal likes to destroy, and what circumstances causes them to become destructive
*
Please check that you understand this is not an acceptance of your pet into our care
Please sign *
Clear