Pet Surrender Application

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email Address*
Pet's Name*
Name
Species*
If Other, please specify:
Breed*
Color*
Gender
Is this pet spayed/neutered?*
- Yes
- No
Age*
Please note, we will also age your pet on intake.
Weight*
If this pet is a cat, is it declawed?
- Yes
- No
Is this pet microchipped?*
Microchip Number
Why are you looking to surrender this pet?*
Have you made alternate attempts to place this pet? If so, where and why was it unsuccessful?*
How long have you had this pet?*
Where did you get this pet? Please list name of organization, rescue, or business.*
Have you attempted to return the pet to that source?
We are dedicated to helping pets and people stay together. If HSP could provide you with resources to keep your pet, which would you benefit from?*
- Free Pet Food
- Free/Low Cost Behavior Advice or Training
- Free/Low Cost Veterinary Care
- Temporary Housing for My Pet
- Benefits for Veterans
- Benefits for Seniors
- Free/Low Cost Spay/Neuter
- Advice on Moving with Pets
- Advice on Pets with Newborns/Kids
- General Pet Ownership Advice
- Other
- I am not interested in getting help to keep my pet
If Other, please specify:
The shelter is very stressful, especially for pets with medical and behavioral needs. Many pets benefit from remaining in a home environment while looking for a new home. If we provided you with everything you will need (food, supplies, vaccinations, surgery, etc.), would you be willing to foster your pet until it is adopted?*
How does this pet react to being brushed, bathed or groomed?*
How does this pet react to having its nails trimmed?*
Is there anywhere this pet does NOT like being touched? If so, where?*
How does this pet behave with other pets? Please describe.*
Does your dog have to be muzzled at the vet?
For dogs, does your dog have to be muzzled in public?
How would you describe your pet's personality?*
- Friendly
- Social Butterfly
- Timid
- Affectionate
- Anxious
- Aggressive
- Aloof
- Playful
- Stubborn
- Rambunctious
- Couch Potato
Choose all that apply.
What animals does your pet live with?*
- None/Not Applicable
- Female Dog(s)
- Male Dog(s)
- Female Cat(s)
- Male Cat(s)
- Male Rabbit(s)
- Female Rabbit(s)
- Male Bird(s)
- Female Bird(s)
- Small Animals (guinea pigs, hamsters, etc.)
- Other
Check all that apply.
Are there certain animal(s) your pet does not get along with?*
- None/Not Applicable
- Female Dog(s)
- Male Dog(s)
- Female Cat(s)
- Male Cat(s)
- Male Rabbit(s)
- Female Rabbit(s)
- Male Bird(s)
- Female Bird(s)
- Small Animals (guinea pigs, hamsters, etc.)
- Other
Check all that apply.
If you selected any animals that your pet does not get along with, please describe.
(If your pet is afraid, aggressive, will chase, has bitten, etc.)
Would you recommend a home with other animals?*
- Dogs
- Cats
- Bird
- Small Animals
- I would not recommend a home with other animals
- Other
Check all that apply.
If you selected "I would not recommend a home with other animals" or "Other," please describe.
How is your pet with strangers?
How is your pet with children?*
Please describe.
Please check who lives with this pet.*
- Adult men
- Adult women
- Children ages 0-2
- Children ages 3-5
- Children ages 6-9
- Children ages 10-15
- Young adults ages 16-21
- Seniors (65+)
Check all that apply.
Is your pet social with visitors?*
Please describe.
Is your pet housebroken and/or use the litter box?*
If Other, please specify:
Please describe your pet's housebreaking or litterbox routine.*
(i.e. how often do you let your dog outside, how often do you clean the litterbox, etc.)
Does this pet have any bad habits?*
(raids the trash, scratches furniture, not housebroken, etc.)
Does this pet live indoors, outdoors or both?*
Is this dog crate trained?*
How long is your pet left home alone?*

Please note time alone in hours per day.
How is your pet housed when left alone (loose, crated, etc.)? How does your pet behave when left alone?
Please check any commands your pet may know.*
- Sit
- Down
- Stay
- Shake/Paw
- Come
- Heel
- Speak
- Other
If Other, please specify:
Describe your pet's training history.*
What veterinary hospital/veterinarian cares for your pet? If applicable, please list their phone number and location.
Our Pet Resource Team may contact your veterinarian to review the pet's medical records.
Can you provide medical records for this pet?*
Records can be brought with you or emailed to [email protected]
Does your pet have any medical conditions that our staff should know about?*
Please describe.
If this pet on any medication(s)?*
Please list any medications your pet is on, including flea/heartworm prevention.
Please check all tests your pet has had within the past year.*
- Heartworm Test (Dogs)
- Feline Leukemia Test (Cats)
- Feline Immunodeficiency Virus Test (Cats)
- None
Did you pet test positive for any of these tests? Which ones?*
Is your pet current on all vaccinations?*
Is your pet on a prescription food?*
What brand/type of food?
Has this pet ever been aggressive?
If Yes, please describe in detail.
Our Behavior Department may be able to work with your pet's aggression.
Has this pet ever bitten anyone?*
If yes, how long ago did the bite occur?
If yes, please describe the circumstances.
This does not mean we will not accept your pet.
Have your previously submitted an application for this pet?*
By checking this box, I certify that all information in this application is true to the best of my knowledge. I understand that HSP is a managed admissions facility and may not be able to accept my pet.*
I understand