First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County*

Email*

Home Phone

Cell Phone*

Please indicate why you need to surrender this pet. Choose all that apply.

If you chose other, please explain:

What is your timeframe for needing to surrender this animal? Please explain. *

Has this animal had any other owners/guardians prior to you? If yes, please give details.

Please indicate where you got this animal: *
Choose one: Breeder Pet Shop Friend or Relative Found/Stray The Marshmallow Foundation Humane Society of the Lakes Lucky Dog Other

If other, please explain:

How long has this animal lived with you? *

Please provide Name/Nickname for animal you are surrendering: *

Please provide animal's date of birth/age: *

Is this an estimate? *
Choose one: Yes No

Sex: *
Choose one: Male Female Unknown

Spayed or Neutered? *
Choose one: Yes No Unknown

Breed(s): *

Does this animal have any health concerns, take any medication, or require any special food? Please be specific and provide as much info as possible. *

Please list the name of the veterinarian or veterinary clinic that last saw this animal and the approximate date of service. Also list any past surgeries or procedures that this animal underwent. If this animal has not been to see a veterinarian or you don't know, please indicate so. *

Where did this dog live? Please check all that apply.

Where was this dog allowed? Please check all that apply.

Please give details about where dog was allowed/not allowed.*

How long was this dog alone on a daily basis? *

Where was the dog kept during the time when no one was home or able to supervise? *

How often was this dog allowed outside for bathroom breaks?*

Do you have a fenced yard?*
Choose one: Yes No

If you have a fence, please tell us how high, what kind of material, if underground, etc. Write N/A if you don't have a fence.*

If your yard is not fenced, how did you keep the dog confined to your property?*

Is this dog house trained? *
Choose one: Yes No Unknown

Does this dog have frequent accidents in the home? Please describe.*

If you answered yes, have you had this dog examined by a veterinarian for possible medical issues? *

Please choose the type(s) of people this animal has lived with. Check all that apply.

Describe current home.

If this animal has been around babies/kids/teens, please describe their behavior:

How did this animal react to visitors? *

Is this animal frightened of anything or anyone (Fireworks, vacuum, men, etc.)?*

Has this dog lived with any other animals? If so, please list type, age, if they were spayed or neutered, and how the dog acted around them. The more details the better. *

Are there any types of animals that this dog DOES NOT like to be around or interact with? Please describe. *

Does this dog chase anything like cars, squirrels, cats, people, etc.?*

To your knowledge, has this dog ever bitten anyone? *
Choose one: Yes No Unknown

If you answered yes, please explain.*

To your knowledge, has this dog ever bitten another animal (not playing)?*
Choose one: Yes No Unknown

If you answered yes, please explain. *

Has this dog ever shown food and/or toy aggression? *
Choose one: Yes No Unknown

If you answered yes, please explain. *

Have you attempted to correct these or other behavior problems? Please describe in detail. *

Has this dog had any training like obedience classes? *

Does this dog know how to sit, stay, walk on a leash, not jump, have recall, etc.? Please be specific. *

Does this animal like to be petted? *
Choose one: Yes No Unknown

Does this animal like to sit in laps? *
Choose one: Yes No Unknown

Are there any areas on the animal that are more sensitive to touch than others? (tummy, rear-end, etc.)*

Is this animal used to having their teeth brushed? *
Choose one: Yes No Unknown

Is this animal used to having their ears cleaned? *
Choose one: Yes No Unknown

Is this animal used to having their nails trimmed? *
Choose one: Yes No Unknown

What kind of food is this animal currently eating? How many times a day? Please provide brand of food, type (wet or dry), etc. *

Please list favorite toys and treats: *

Please provide any additional information that will enable us to find a new home for this animal: *

How did you hear about our shelter?

If you chose other, please indicate how you learned about our shelter: