Dog and Cat Surrender Form - Espanola Humane

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Dog and Cat Surrender FormBen Swan2024-01-04T11:46:25-07:00

Owned Cat and Dog Intake

Date
MM slash DD slash YYYY
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email
What is the species of the pet your are surrendering?*
- Dog
- Cat
- Rabbit or small mammal
What is the breed and size of the pet you are surrendering?*
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.
What are the best things about 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?
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?

Shelter:
108 Hamm Parkway
Española, NM 87532

Animal Clinic:
2126 El Llano Road
Ohkay Owingeh, NM 87556
Clinic Hours:
Monday, Tuesday, Wednesday, Thursday, and Friday
By Appointment Only

Shelter Hours:
Monday – Saturday, closed on Sunday
11 am – 5 pm, last adoption at 4:30 pm
Clinic: 505-753-8662, Ext. 200/202
Shelter: 505-753-8662
[email protected]

Charity-Navigator-Platinum-Transparancy-2025

Española Humane is a 501(c)(3) nonprofit.
Our tax-ID is 85-0406234 and donations may be tax-deductible.

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