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Dog Owner Surrender Form
On this form, please provide detailed information on the behavioral and medical history of the companion animal to be considered for surrender.
Email address *
Owner's First Name *
Your answer
Owner's Last Name *
Your answer
Please Select Your County *
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Animal's Name *
Your answer
Animal's Age (Years) *
Your answer
Animal's Breed or Mix *
Your answer
Animal's Color *
Your answer
Animal's Weight *
Your answer
Requirement for Proof of Ownership
To surrender an animal, owner's must provide proof of ownership. These records need to be at least 30 days old and in the name of the person surrendering the animal. Proof of ownership types include a veterinary record, adoption paperwork, or bill of sale. (In accordance with California food and agricultural code section 31108.5 and 31752.2)
Do you have proof of ownership?
Reason(s) for needing to re-home your animal *
Required
I would consider keeping my dog if *
Required
How long have you owned your animal? *
Your answer
Where did you get this animal from? *
Is the animal kept primarily indoors? *
Is your animal houstrained? *
Including yourself, check off the number of people who live in the house along with each person's age. *
0 people
1 person
2 people
3 people
4 people
5 people
6 people
7 people
Ages 0-3
Ages 4-9
Ages 10-17
Ages 18-29
Ages 30-59
Ages 60+
What other animals does your dog live with?
How does your dog usually behave toward the following?
People your dog knows: Men *
Required
People your dog knows: Women *
Required
People your dog knows: Children *
Required
Unfamiliar people: Men *
Required
Unfamiliar people: Women *
Required
Unfamiliar people: Children *
Required
Animals your dog knows: Dogs *
Required
Animals your dog knows: Cats *
Required
Unfamiliar animals: Dogs *
Required
Unfamiliar animals: Cats *
Required
Does your dog usually uncontrollably chase or attempt to chase any of the following? Please check all that apply. *
Required
How does your dog usually react when you or another family member does the following?
Give a bath *
Brush fur *
Clean or dry paws *
How does your dog usually react when an unfamiliar person approaches or enters the yard or the house? *
Do you take your dog out to go to the bathroom? *
If yes, how many times per day do you take your dog outside to use the bathroom? *
Your answer
Does your dog usually have "accidents" in the house? *
If yes, how many accidents does your dog have per day? *
Your answer
Where does your dog spend most of his/ her time? *
How long is your dog left alone, without people, during the day? *
When your dog is left alone, is he/she... *
When left alone, does your dog usually show any of the following behaviors? Please check all that apply. *
Required
When you are at home, does your dog usually show any of the following behaviors? Please check all that apply. *
Required
When your dog plays, does he/ she typically... Please check all that apply. *
Required
What toys does your dog like? *
Required
What games does your dog like? *
Required
Is your dog scared of anything? *
Your answer
Please tell us your dog's "bad habits" *
Your answer
Is your dog allowed on the furniture? *
Where does your dog usually sleep overnight? *
What commands does your dog know? *
Has your dog attended any obedience training classes? If yes, please describe and list where/ who you worked with. *
Your answer
If you have worked with a trainer, may we contact them? *
Your answer
Has your dog ever been walked on a leash? *
Does your dog have problems riding in the car? *
Has your dog escaped your property two or more times in the last *
If your dog has escaped more than once in the last six months, please describe the circumstances. *
Your answer
Is there any report of your dog ever inflicting a serious bite to a person (such as an attack or a bite requiring hospitalization)? *
Has your dog ever attacked another dog resulting in severe injury or death to another dog? *
Has your dog ever attacked another domesticated animal species (cats or livestock but not “small pets” like hamsters, guinea pigs, etc.) resulting in severe injury or death to another domesticated animal? *
Aggressive Behavior
Please check the appropriate box if your dog has ever shown any of the following aggressive behaviors toward men, women, children, dog, or another domesticated animal species (cats or livestock, not “small pets” like hamsters, guinea pigs, etc.) Do not include aggressive behaviors directed toward a veterinarian or groomer.
Men *
Required
Women *
Required
Children *
Required
Dog *
Required
Other domestic animals (cat, livestock, etc.) *
Required
If a snap or bite to an adult was checked, did the snap or bite take place while breaking up a dog fight or when the dog was in severe pain? *
If a snap or bite to children was checked, did the snap or bite take place while breaking up a dog fight or when the dog was in severe pain? *
Please explain the circumstances of the snap or bite. If you checked more than one bite above, please explain the circumstances of every snap or bite. *
Your answer
If any aggressive behavior to men, women, or children was checked above, explain the reason by checking an answer below. *
Required
Medical History
Does your dog see a veterinarian at least once a year? *
Is your dog up to date on vaccinations? *
Is your dog spayed or neutered? *
Veterinarian name and contact information *
Your answer
Check below if your dog has ever shown any of the following aggressive behaviors when handled by a veterinarian or groomer.
Examine (including heart and ears) *
Restrain *
Administer shots *
Trim nails *
Take blood *
Does your dog have to be muzzled at the veterinarian? *
Please list any past or present medical conditions. *
Your answer
Is your dog currently on any medication or special diet? *
Your answer
What type of food does your dog eat? *
Required
If my dog is over the age of 8 years old, I agree to obtain a blood panel to confirm my he/she is in good health. *
If my pet is accepted by the East Bay SPCA, I understand and agree to the following: *
Required
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