QHCC Owner Surrender Form
Email address *
Date of Surrender
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Name of Owner
Your answer
Address
Your answer
Phone Number
Your answer
E-mail Address
Your answer
Pets Name and Age
Your answer
Pets Gender
Breed and Weight
Your answer
Is the pet neutered/ spayed?
Date of last vet visit
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Date of Last Dhlpp Vaccine
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Date of Last Rabies Vaccine
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Contact information for vet
Your answer
What brand of flea preventative is being used?
Your answer
What brand of monthly heartworm preventative is being used?
Your answer
Date of last heartworm test
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Heartworm status
Please list any known medical conditions
Your answer
Is the pet microchipped?
Has the pet ever bitten another pet or person? (If you select no: I swear to the fact to the best of my knowledge, this dog has never bitten another dog or human and that this dog has never shown any aggressive behavior. I further understand any attempts to mislead or falsify information will result in my dog being denied acceptance into QHCC. If the answer is yes please explain. A bite history does not make an animal ineligible to enter the QHCC foster system it simply gives us all the necessary information to place the dog effectively.)
Your answer
Where was the dog previously purchased or adopted from?
Your answer
Why are you surrendering this pet?
Your answer
Does your dog have any food or environmental allergies? If yes, please describe in detail:
Your answer
Is your dog food or toy aggressive?
Is your dog good with cats?
Is your dog good with other dogs?
Is your dog good with children?
Does your dog dig out of fenced areas?
Does your dog climb out of fenced areas?
Please type name below to transfer ownership to QHCC and to release veterinary records to QHCC staff upon request (Note: Typing name constitutes digital signature and shall be treated as a customary written signature for purposes of executing this legal document. By typing your name you are acknowledging that you are the owner of this canine and have legal rights to surrender canine to QHCC.):
Your answer
Please enter today's date below:
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