Surrender Request Form

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Please fill out this form to the best of your ability. Your answers will help us get to know the animal and give us some background information. This will ensure that we are able to place him/her in a new home that is best matched with his/her personality and needs. HART of Maine cannot guarentee any intake and submission of this form does not guarentee an intake for your pet. HART schedules appointments for each intake and cannot accept same-day walk ins. If you have any questions, please reach out to intake@hartofme.org.
Is this an urgent request? If yes, please explain.
Name *
Street Address *
City, State *
Zipcode *
Email *
Confirm email
Home Phone
Cell Phone *
When do you need to surrender your pet by? *
This section is all about your cat. Please provide as many details as possible.
Cat's Name *
Gender *
Color	Black Black and White Black and White - Spotted Black and White - Tuxedo Black with White Black with White Socks Blue Blue Point Brown (chocolate) Brown (chocolate) and White Buff Buff and White Buff with White Calico Calico, Dilute Chocolate Chocolate Point Cinnamon Cream Cream Point Flame Point Gray Gray and White Gray w/ White Lilac Point Lynx Point Orange Orange and White Orange w/ White Other Red Ruddy Seal Point Smoke Snow Shoe Tabby, Brown and White Tabby, Brown-Dark Tabby, Brown-Light Tabby, Brown w/ White Tabby, Buff Tabby, Buff and White Tabby, Buff w/ White Tabby, Gray Tabby, Gray and White Tabby, Gray w/ White Tabby, Orange Tabby, Orange and White Tabby, Orange w/ White Tabby, Patch Tabby, Patch and White Tabby, Patch, Dilute Tabby, Patch, Dilute w/ white Tabby, Patch w/ White Tabby, Silver Tabby, Silver and White Tabby, Silver w/ White Tabby, Smoke Tabby, Smoke & White Tortie Tortie, Dilute Tortie, Dilute w/ White Tortie Point Tortie w/ White Unknown White White with Black White with Brown White with Gray White with Orange
Breed
Is your cat microchipped? *	NoYes
Is your cat spayed or neutered? *	NoYes
Is your cat indoor or outdoor? *	Indoor Outdoor Both Barn
Is your cat declawed? *	NoYes
Are you the owner of this cat? *	NoYes
Is this a HART return? *	NoYes
Where did you originally get this cat? *
How long have you had this cat? *
This section asks questions about your cats medical history. Please provide as many details as possible.
Has your cat been to the vet in the past year? *	NoYes
Please list the name of any veterinarian or veterinary clinics your cat has ever been to.
Is your pet up to date on vaccinations? *	NoYes
Does your cat have any diagnosed medical conditions? *	NoYes
Does this cat have any suspected medical needs? *	NoYes
If yes, please explain:
If yes, please explain:
Does your pet take any prescription medications or supplements? *	NoYes
If yes, please list them:
Does your cat require a special or prescription diet? *	NoYes
If yes, please list:
This section asks questions about your cats behavior history. Please provide as many details as possible.
Has your cat lived with other animals before? *	NoYes
If yes, please list reaction to other pets:
Please list the ages of people your cat has lived with: *
Please describe your pets personality: *
Please select all that apply: *	Active CouchPotato Playful Talkative Reserved Dominant Destructive Independent Cuddly Lap Cat Friendly with Family Friendly with Visitors Shy with Family Shy with Visitors
Please select any of these behaviors your cat has expressed:	Scratching Furniture Chews Plants Chews Electrical Cords Chews Fabric or Cloths Jumps on Counters Spraying or Marking Inappropriate Urination Escapes Climbs Curtains Bites or Swats Other
Does your cat use the litterbox consistently? *	NoYes
If no, please explain: *
What type of litterbox does your cat prefer? *	Covered Uncovered Robot (ex: Litter Robot) Does not use litterbox
Is there anything else you would like to share about your cat?
By submitting this form, I hereby certify that I am the rightful owner/keeper/caretaker/custodian of the animal(s) who is/are the subject of this Animal Surrender Form, hereinafter referred to as “the cat.” I hereby surrender any and all property rights of the animal. I release and discharge HART from any and all claims, obligations, liabilities, and causes of action whatsoever arising out of or relating to the ownership, possession, or disposition of the animal(s) and agree to hold harmless HART from and against any and all such rights claims, obligations, liabilities and causes of action which may be asserted by other parties. I certify that no other person has a right of property to the animal. 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.
Signature *	Clear