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 Information

Name *

First Last

Email *

Address *

Street Address City State ZIP Code

Phone Number *

Phone Number (Alternate) *

Date *

Pet and Household Information

Pet’s Name *

Sex *

Male
Female

Age *

Breed *

How long have you had this pet? *

Is your pet spayed or neutered? *

Yes
No

Why 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? *

Yes
No

*

What other animals did your pet live with? *

No other animals in the household
Dogs
Cats

If you have other pets in the household, does your pet interact with them? *

Yes
No
Sometimes

*

Typical Behavior/Tendencies

How 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? *

Outside
Inside 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 knows

Men *

Never Encounter
Friendly
Afraid
Scratches
Bites
None

Women *

Never Encounter
Friendly
Afraid
Scratches
Bites
None

Children *

Never Encounter
Friendly
Afraid
Scratches
Bites
None

Unfamiliar People

Men *

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 knows

Dogs *

Never Encounter
Friendly
Afraid
Scratches
Bites
None

Cats *

Never Encounter
Friendly
Afraid
Scratches
Bites
None

Unfamiliar Animals

Dogs *

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? *

Yes
No

What toys or treats does your pet like? *

What are your pet’s ‘bad habits’? *

What is your pet’s best quality? *

Medical History

Does your pet see a veterinarian at least once a year? *

Yes
No

Veterinary Clinic Name *

Contact Info *

Is your pet current on his/her vaccines? *

Yes
No
NA

If 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? *

Yes
No

*

Is your pet currently on any medication or special diet? *

Yes
No

*

What type of food does your pet eat? *

Give Us a Call:

Office Hours:

Adoption Hours:

Small Animal Surrender Profile Form

Owners Information

Pet and Household Information

Typical Behavior/Tendencies

Medical History

262-782-9261

262-782-3356

Elmbrookhs@ebhs.org