Surrender or Return

Surrender or Return - Dog

Animals brought to HSMC, who have been in a household and are being surrendered

Surrender / Return Dog Please be as specific as possible. Thank you for your open and honest answers. Your donation to cover costs while in our care, is greatly appreciated. Please let us know the dollar amount you would like to donate.

Today's Date:
Owner first name: *
Last name: *
Surrendered by if different than owner:
Address: *
City: *
State: *
Zip: *
Cell/phone: *
Email:
Dog's Name *
Sex *	Female Male
Age: *
Breed *
Altered: *
Altered date:
Why are you surrendering: *
How long has the dog lived with you: *
How many owners has this dog had: *
Share 3 things you like about your dog and want others to know: *
Any special medical or dietary needs (include medications and food given): *
Any previous health issues or injuries (surgeries, seizures, fractures, allergies, etc):
Current on Vaccinations - PLEASE PROVIDE COPY OF MOST RECENT VET RECORDS: *
Date last Vet visit, Vet name/phone #: *
Has your dog ever bitten a person: *
How many people and how many times: *
Did the bite: *	Draw blood Leave a mark Bruise
If yes, please explain: *
Explain who was bitten, when and where was bite located: *
If no, please explain: *
Specifics of what provoked the incident: *
Situations or items that cause your dog to growl, snarl, bark, lunge, snap or otherwise act aggressively towards people: *	Food Toys Restraint Bones/Rawhide Stolen Objects Hugging/Kissing Disturbed when sleeping Stranger entering the yard/home Reaching for Dog or grabbing Collar Brushing/bathing Nail trimming other N/A
Describe severity of behavior for each situation indicated above: *
Situations or items that cause your dog to growl, snarl, bark, lunge, snap or otherwise act aggressively toward other dogs or cats. Select all that apply: *	Food Toys Bones/Rawhide Stolen Objects Attention from Owner Dog entering home/yard or walking too close On bed or furniture Other N/A
Has dog ever attacked/killed another animal: *
Explain type of animal, severity of bite, when and why it occurred: *
Has your dog ever visited:	Homes with other dogs Dog parks Dog friends he plays with on a regular basis Cat friends
Number and ages of children under 18 your dog has lived with or regularly visited:
How did they interact:
Other animals your dog has lived with and how did they interact: *
Did your dog have accidents in the house: *
How often, when and where was house soiled:
How often do you take your dog outside to go to the bathroom: *
List things dog is afraid of:
Is dog allowed on the furniture:
Where does dog sleep:
Does dog enjoy car rides:
Gets car sick:
Does dog escape from the yard or house:
How often and how does he escape:
Is your yard fenced. If so, type and height:
Where does your dog predominantly live:	Inside Outside Both
One average, how many hours a day is your dog alone: *
Where do you leave your dog when no one is home:	Outside Free inside Confined to a room In a crate Other
Check all words describing your dog: *	Calm Friendly Energetic Independent Playful Fearful/shy Anxious Confident Aggressive
When left alone, check all that apply: *	Destroy household items Urinate/defecate Barks constantly Cry/whine Howl constantly Breaks out of crate/kennel Chews/scratches doors and windows N/A
Does it matter how long you are gone:
Favorite toys and games
List commands and tricks known:
What would you change about your dog:
What do you feed your dog / How often / How much: *
Information you want to share about your dog:
Select the level of exercise that best describes what your per requires/prefers: *	Low: Spends most of day sleeping/resting, occasional walks or play time Mild: Likes to play for a while, take a few short walks daily, then relaxes Moderate: Multiple medium/long walks daily or longer playtime/fetch High: Regular jobs/run or sports activities like frisbee/agility/fly ball
I, owner of said animal relinquish all rights of ownership, understand that Helping Strays personnel are under no obligation to release any information regarding the disposition of said animal, and give shelter permission to contact any veterinarians or animal care facility regarding the medical records of said animal. Owner Signature: *
To the knowledge of the owner, said animal has not bitten anyone. Owner Signature: *