Full Name *

Address *

Postal code *

Phone *

Email *

What type of animal? *

Dog

Cat

Is your dog on heartworm preventative? *

Yes

No

I don't know

What breed is your pet? *

Has your dog tested positive for heartworms? *

Yes

No

I don't know

How much does your pet weigh? *

Were is your cat in the day? *

Where is your cat during the night? *

Animal's Name

Age of the animal or date of birth? *

Are you the legal owner of this animal? *

Yes

No

How did you get your animal? *

Is your animal up to date on flea preventative? *

Yes

No

I don't know

Is your animal Spayed/Neutered? *

Yes

No

I don't know

Is your animal up to date on vaccinations? *

Yes

No

I don't know

Has the animal been treated for any medical conditions? If so, what have they been treated for? *

Has the animal ever shown aggression towards another person/animal? *

Yes

No

I don't know

Has your animal ever bitten someone? *

Yes

No

I don't know

Has your animal ever killed or injured an animal? *

Yes

No

I don't know

Is the animal social with people? *

What other animals live in the home? Dogs, Cats, Livestock, Birds? *

Why do you want to relinquish ownership of the animal? *

Please upload a picture of your pet *