Companion Animal Surrender Form ___ Dog ___ Cat ___ Rabbit

Owner Name: ______Date: ______

Address: ______Email: ______

City, State and Zip: ______Home Phone # ______

The information provided on this form is used to assist us in providing a suitable home for this pet. We ask the owneror custodian of this animal to answer all questions as accurately and honestly as possible.

Cat Profile:

Cat’s Name: ______Age: ______Breed: ______

Gender: ______Spayed/Neutered ______Yes _____ No

Is the cat [circle one] Indoor only Indoor/Outdoor Outdoor only

Is the cat declawed: ____ Yes ____ No Is the cat litter box trained? ____ Yes ____ No

If yes, what brand of litter have you been using? ______

Does your cat get along with [circle all that apply]: Other Cats Dogs Other animals Children

Cat’s Current Veterinarian: ______Phone: ______

Tested for Leukemia? _____ Yes ____ No

Date of Vaccinations: Rabies: ______Leukemia/Distemper: ______

Describe any health problems, injuries, or medication that the cat has/is taking:

Describe your cat’s personality and activities it enjoys:

Describe the cat’s feeding routine [frequency, type of food, brand, etc.]

Dog Profile:

Dog’s Name: ______Age: ______Breed: ______

Gender: ______Spayed/Neutered ______Yes _____ No

Does your dog get along with [circle all that apply]: Male Dogs Female Dogs Cats Birds Livestock Other small animals Children Under 10 yrs.

Is the dog:House Trained? __ Yes __ No Crate Trained? __ Yes __ No Leash Trained? __ Yes __No

Dog’s Current Veterinarian: ______Phone: ______

Date of Vaccinations: Rabies: ______Parvo/Distemper: ______Bordatella: ______

Describe any health problems, injuries, or medication that the dog has/is taking:

Describe your dog’s personality and activities it enjoys:

Describe the dog’s feeding routine [frequency, type of food, brand, etc.]:

Describe any negative behaviors the dog has engaged in [growled at or bitten a person or other animal, possessive over food, chewing, excessive barking, etc]

Rabbit Profile:

Rabbit’s Name: ______Age: ______Breed: ______

Gender: ______Spayed/Neutered ______Yes _____ No

Rabbit’s enclosure is: _____ A cage ____ An outdoor hutch _____ None – Free roaming

_____ Other: ______

How much time does the rabbit spend outside his/her enclosure? ______

The rabbit has lived with: ___ Other rabbits ___ Dogs ___ Cats ___ Children ___ Other

Describe any health problems, injuries, or medication that the rabbit has/is taking:

The rabbit was last seen by a veterinarian on: ______at ______

Date Vet Practice/Vet’s Name

The rabbit usually eats [check all that apply]:

_____ Timothy Hay _____ Orchard Grass_____ Pellets [list brand] ______

_____ Carrots &/or Fruit [what?] ______Greens [what?] ______

_____ Other: ______

Describe your rabbit’s personality and activities it enjoys:

Surrender Donation:

Will you be making a tax deductible donation to help cover the costs of caring for the surrendered animal[s] while it is at Honey Do Animal Rescue, Inc.? ______Yes ______No. If yes, the tax deductible donation is in the amount of $ ______.

Acknowledgement:

I agree that I, my spouse, or any other co-owner of the animal[s] described on this form are irrevocably transferring and relinquishing to Honey Do Animal Rescue, Inc. legal ownership of said animal[s]. This gives Honey Do Animal Rescue, Inc. complete authority to take whatever action they deem necessary and in the best interest of the animal.

I acknowledge that To the best of my knowledge, the above surrender information about the companion animal’s history is true and correct.

I understand that the Honey Do Animal Rescue, Inc. will not be responsible for any financial obligations incurred by me on behalf of the animal[s] described on this form prior to its [their] surrender to Honey Do Animal Rescue, Inc..

______

Owner Signature Date Signed

Companion Animal Surrender – page 1