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 First Last Email Address 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 NumberPhone Number (Alternate)Date - must be mm/dd/yyyy format Date Format: MM slash DD slash YYYY Pet and Household InformationPet’s NameSexMaleFemaleAgeBreedHow long have you had this pet?Is your pet spayed or neutered?YesNoWhere did you acquire this pet?EBHSFriend/RelativeNewspaper/OnlineFound/strayBreederPet StoreWhy are you surrendering this pet? Including yourself, how many people of the following ages live in your household?Male (0-3yrs)Female (0-3yrs)Male (4-9yrs)Female (4-9yrs)Male (10-17yrs)Female (10-17yrs)Male (18-29yrs)Female (18-29yrs)Male (30-59yrs)Female (30-59yrs)Male (60+yrs)Female (60+yrs)If you checked off children under the age of 10, is your pet tolerant/friendly toward the children?YesNoWhat other animals did your pet live with?No other animals in the householdDogsCatsIf you have other pets in the household, does your pet interact with them?YesNoSometimesTypical Behavior/TendenciesHow does your pet usually react when you or another family member do the following to him/her? (Please check boxes)Bathe Never Tried Enjoys Allows Afraid Scratches Bites None Brush Never Tried Enjoys Allows Afraid Scratches Bites None Hold Never Tried Enjoys Allows Afraid Scratches Bites None Hug Never Tried Enjoys Allows Afraid Scratches Bites None Pick up Never Tried Enjoys Allows Afraid Scratches Bites None Where does your pet spend most of his/her time?OutsideInside the house (free roam)Inside the house (confined to a cage)What type of cage is it and how big? 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 Never Encounter Friendly Afraid Scratches Bites None Women Never Encounter Friendly Afraid Scratches Bites None Children Never Encounter Friendly Afraid Scratches Bites None Unfamiliar PeopleMen Never Encounter Friendly Afraid Scratches Bites None Women Never Encounter Friendly Afraid Scratches Bites None Children Never Encounter Friendly Afraid Scratches Bites None Animals your pet knowsDogs Never Encounter Friendly Afraid Scratches Bites None Cats Never Encounter Friendly Afraid Scratches Bites None Unfamiliar AnimalsDogs Never Encounter Friendly Afraid Scratches Bites None Cats 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.Is your pet litter box trained?YesNoWhat toys or treats does your pet like?What are your pet’s ‘bad habits’?What is your pet’s best quality?Medical HistoryDoes your pet see a veterinarian at least once a year?YesNoVeterinarian NameContact InfoIs your pet current on his/her vaccines?YesNoNAIf 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) Hisses/swats Scratches Bites None Restrain Hisses/swats Scratches Bites None Administer vaccines Hisses/swats Scratches Bites None Trim Nails Hisses/swats Scratches Bites None Draw Blood Hisses/swats Scratches Bites None Does your pet have any past or present medical conditions?YesNoIs your pet currently on any medication or special diet?YesNoWhat type of food does your pet eat?