Small Animal Surrender Profile Form Small Animal Profile The following questionnaire provides Elmbrook Humane Society (EBHS) with more information about your pet in order to learn more about his/her behavior. Because your pet is likely to behave in similar ways in his/her new home, this information helps us find the most suitable match for your pet. Your open and honest answers are necessary and appreciated. I certify that the information I am about to provide is accurate and truthful to the best of my knowledge. Owners InformationName * Required First Last Email * Required Address * Required Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number * RequiredPhone Number (Alternate) * RequiredDate - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY Pet and Household InformationPet’s Name * RequiredSex * RequiredMaleFemaleAge * RequiredBreed * RequiredHow long have you had this pet? * RequiredIs your pet spayed or neutered? * RequiredYesNoWhere did you acquire this pet? * RequiredEBHSFriend/RelativeNewspaper/OnlineFound/strayBreederPet StoreWhy are you surrendering this pet? * Required Including yourself, how many people of the following ages live in your household?Male (0-3yrs) * RequiredFemale (0-3yrs) * RequiredMale (4-9yrs) * RequiredFemale (4-9yrs) * RequiredMale (10-17yrs) * RequiredFemale (10-17yrs) * RequiredMale (18-29yrs) * RequiredFemale (18-29yrs) * RequiredMale (30-59yrs) * RequiredFemale (30-59yrs) * RequiredMale (60+yrs) * RequiredFemale (60+yrs) * RequiredIf you checked off children under the age of 10, is your pet tolerant/friendly toward the children? * RequiredYesNo * RequiredWhat other animals did your pet live with? * RequiredNo other animals in the householdDogsCatsIf you have other pets in the household, does your pet interact with them? * RequiredYesNoSometimes * RequiredTypical Behavior/TendenciesHow does your pet usually react when you or another family member do the following to him/her? (Please check boxes)Bathe * Required Never Tried Enjoys Allows Afraid Scratches Bites None Brush * Required Never Tried Enjoys Allows Afraid Scratches Bites None Hold * Required Never Tried Enjoys Allows Afraid Scratches Bites None Hug * Required Never Tried Enjoys Allows Afraid Scratches Bites None Pick up * Required Never Tried Enjoys Allows Afraid Scratches Bites None Where does your pet spend most of his/her time? * RequiredOutsideInside the house (free roam)Inside the house (confined to a cage)What type of cage is it and how big? * Required How does your pet usually react when you or another family member do the following to him/her? (Please check boxes) People your pet knowsMen * Required Never Encounter Friendly Afraid Scratches Bites None Women * Required Never Encounter Friendly Afraid Scratches Bites None Children * Required Never Encounter Friendly Afraid Scratches Bites None Unfamiliar PeopleMen * Required Never Encounter Friendly Afraid Scratches Bites None Women * Required Never Encounter Friendly Afraid Scratches Bites None Children * Required Never Encounter Friendly Afraid Scratches Bites None Animals your pet knowsDogs * Required Never Encounter Friendly Afraid Scratches Bites None Cats * Required Never Encounter Friendly Afraid Scratches Bites None Unfamiliar AnimalsDogs * Required Never Encounter Friendly Afraid Scratches Bites None Cats * Required Never Encounter Friendly Afraid Scratches Bites None Please explain the circumstance of the scratch or bite (if applicable). If you checked more than one bite or scratch above, please explain the circumstance of each. * RequiredIs your pet litter box trained? * RequiredYesNoWhat toys or treats does your pet like? * RequiredWhat are your pet’s ‘bad habits’? * RequiredWhat is your pet’s best quality? * RequiredMedical HistoryDoes your pet see a veterinarian at least once a year? * RequiredYesNoVeterinary Clinic Name * RequiredContact Info * RequiredIs your pet current on his/her vaccines? * RequiredYesNoNAIf your pet has ever shown any of the following aggressive behaviors when handled by a veterinarian or groomer please check all that apply.Examine (ears, teeth etc) * Required Hisses/swats Scratches Bites None Restrain * Required Hisses/swats Scratches Bites None Administer vaccines * Required Hisses/swats Scratches Bites None Trim Nails * Required Hisses/swats Scratches Bites None Draw Blood * Required Hisses/swats Scratches Bites None Does your pet have any past or present medical conditions? * RequiredYesNo * RequiredIs your pet currently on any medication or special diet? * RequiredYesNo * RequiredWhat type of food does your pet eat? * Required