Pet Background Form

2010 Arcadia Street

Fort Myers, Florida 33916

Office: (239) 332-0364 Fax: (239) 332-8676

PET BACKGROUND FORM

Pets Name______Species______Breed______Color______

Age or Date of Birth______Sex______Altered ______Declawed______

Why are you surrendering your pet? ______

______

How long have you had your pet? ______. Where did you acquire your pet? ______

Is your pet current on heartworm & flea prevention? ______.What brand? ______

When was it given last? ______

What brand of food does your pet eat? ______. How often______

Does your pet have any current or past health conditions or injuries? ______

______

Who does your pet get along with? Please circle Men Women Children (ages)_____ Dogs Cats Otheranimals

Does your pet live indoor, outdoors or both? ______. Where does your pet sleep? ______

Has your pet ever shown signs of aggression such as biting, snapping , growling, food aggression, aggression towards animals, aggression towards people or children?______

If yes, was the aggression provoked? Please explain______

Does your pet have any bad habits such as digging, fence jumping, scratching furniture, chewing, barking or jumping on people?______

Is your pet house trained or litter trained? ______

Does your pet allow you to.....? (Circle all that apply) Trim nails/ grooming/ clean ears/ Bath Brush Teeth

Does your pet have any obedience training? ______Does your pet know any commands? ______

Please tell us about your pet and any special characters, personality traits, or special needs______

______

PET INTAKE FORM

Owner Name______Date______

Address______City ______State_____ Zip______

Phone Number______Alternate Number______

Pets Name ______Species ______Breed ______Color______

Age or DOB ______Sex ______Altered ______Declawed ______

Eye Color ______Distinguishing Marks ______Microchip ______

Pattern:(Please Circle) Bi-color Tri-color Calico Brindle Dilute Harlequin Merle Point Roan

Salt/Pepper Solid Spotted Tabby Tick Tortoiseshell Tuxedo

Coat:(Please Circle) Short Medium Long Wiry Curly Smooth Silky Wavy

Ears: (Please Circle) Cropped Droopy Erect Long Notched Semi-erect Tipped

Tail: (Please Circle) Bob Curled Docked Kinked Long Missing Short

Owner Surrender______Stray ______Return ______

Statement of Surrender

I certify that I do ___ /do not ____ own the animal described above and hereby surrender all interest to the Gulf Coast Humane Society. My interest in this animal has now been voided and I will not be given any information on the welfare or disposition of this animal. Initials ______

There is no minimum set time for holding this animal. The holding time depends on the animal’s health, behavior, and adoptability. It is also agreed that neither said society nor its management and employees shall incur any obligation to me on the disposition of the above listed animal. I certify that this animal has not bitten another animal or humane within the last 10 days. Initials______

I have read and understand that I have surrendered my rights and interest towards this animal.

Signature______Date ______

I would like to make a donation in the amount of $______to the Gulf Coast Humane Society to assist I the care of the animals in need.

Signature______Date______

2010 Arcadia Street

Fort Myers, Florida 33916

Office: (239) 332-0364 Fax: (239) 332-8676