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108 Hamm Parkway
Española, NM 87532
Shelter: 505-753-8662
Clinic: 505-753-0228
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contact@espanolahumane.org
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Dog and Cat Surrender Form
Ben Swan
2021-07-24T19:55:04-07:00
Owned Cat and Dog Intake
Date
Date Format: MM slash DD slash YYYY
Name
*
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Email
What is the reason you are surrendering you pet?
*
Is there anything we can do or provide to assist you in keeping your pet?
*
Where did you get your pet?
*
Is your pet microchipped?
*
Yes
No
If yes, is the microchip linked to you or a previous owner?
Where does your pet stay during the day? At night?
*
Describe your pet's personality.
Describe your pet's personality.
What are the best things about your pet?
Who lives in the home with your pet?
Any interactions with children?
If so, how old and how did the pet interact?
Any interactions with large/small dogs or cats?
If so, how did the pet react?
Does the pet know any commands?
For dogs, how does your dog behave on leash?
What kind of home would you recommend for your pet?
Do you have any behavior concerns about your pet?
Yes
No
If so, what are they? In what circumstances do these behaviors happen?
Have you noticed anything that helps improve this behavior?
Has the pet bitten or scratched anyone in the past 10 days?
Yes
No
If so, add a bite memo and place on quarantine.
Has the pet ever bitten a person?
Yes
No
If so, add a bite memo.
Was this pet spayed/neutered?
Yes
No
If so, when was the surgery?
When was the last time you saw a veterinarian?
Is your pet on any medications or special diets?
Yes
No
If so, describe.
Is your pet displaying any concerning medical symptoms?
Yes
No
If so, what are the concerns?
If so, how long has the condition/symptoms been going on?
Was your pet seen by your veterinarian for this issue?
Yes
No
If so, what is the name of the veterinarian clinic and can you provide us with the medical records?
If so, do you know of any treatments, medications or prescription diets given or recommended?
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