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Owner Surrender Supplemental Form
Please fill out the following form honestly to assist us in making a suitable match for your surrendered companion. Thank you!
Your name *
Your answer
Your Address: *
Your answer
Your contact information (email & phone) *
Your answer
Pet’s name *
Your answer
Dog or Cat and Breed if known *
Your answer
Age *
Your answer
Spayed or Neutered *
How long has animal lived with you? *
Your answer
Please explain why you are relinquishing your pet? *
Your answer
Name and phone number of your veterinarian: *
Your answer
Does your pet have any medical issues? *
Your answer
If you answered yes to the previous question, how is this condition controlled? (example: medicine, special diet, etc...)
Your answer
What does a 24 hour period look like for your pet? *
Your answer
Has your pet ever escaped from the yard or house? If yes, please explain. *
Your answer
For how many hours is your pet comfortable being left alone? *
Your answer
Has your pet ever been introduced to a crate? *
If you answered yes to the previous question, please explain their behavior in the crate.
Your answer
Is your pet housetrained/litter box trained? *
Under what circumstance might he/she have an accident? *
Your answer
What is your pet's favorite game or activity? *
Your answer
Who is your pet's favorite person to be with? *
Your answer
How does your pet generally show affection? *
Your answer
How does your pet generally greet strangers in the home? *
Your answer
How does your pet greet strangers/other animals outside of the home (on a walk, or at park)? *
Your answer
How does your pet behave at the vet? If they've had a negative experience, please explain that as well. *
Your answer
What commands does your pet know? *
Your answer
Has your pet had experience with children? *
If you answered yes to the previous question, please explain what ages of children and under what circumstances.
Your answer
Would you recommend that your pet be placed in a home with children? If no, please explain. *
Your answer
Does your pet display any behaviors that the new adopters will need to be aware of? If yes, please explain. (ex. Chewing, excessive barking, separation anxiety, etc...) *
Your answer
Has your pet ever growled at you or anyone else? If yes, please explain. *
Your answer
Select all of the behaviors that your pet has exhibited to you or anyone else. *
Required
If your pet has shown any signs of aggression, please explain:
Your answer
Does your pet have any fears? If so, what are they? *
Your answer
What does your pet do when he/she is frightened? *
Your answer
Is your pet sensitive about being handled in any way? If yes, please explain. *
Your answer
Has your pet lived with other animals? If so, what kinds, how old, how many? *
Your answer
If your pet has lived with other animals, was it successful? Please explain.
Your answer
Has your pet ever fought with another animal? If yes, please describe the situation (were toys, food, or rawhides involved?) *
Your answer
Has your pet ever injured another animal? If yes, please explain and include where the other animal injured and how severe was the injury? *
Your answer
Please use this box for any additional information you would like to share about your pet.
Your answer
Signature/Agreement: I understand that by selecting "I Accept" it constitutes a legal signature confirming that the above information is truthful to your knowledge. You also agree to give permission to the Wellington Humane Society to contact my veterinarian and obtain my pet's medical history. I also understand that my pet is now under the care of WHS. *
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