2. Owner Name (First, Last):*
4. Current Street Address (proof of residency must be shown, if the address entered here does not match driver license or other form of approved valid identification surrender request may be denied as we only serve Cedar Hill, DeSoto, and Duncanville)*
6. Phone Number:*
8. Email Address:*
10. Reason for pet surrender (please provide detailed information)*
12. Have you tried looking into help for the reason of surrender?*

    1. Yes
    2. No
    3. I request additional assistance on keeping my pet and would like Tri-City to contact me for more options
14. Please fill out the following in as much detail as possible. Accurate and detailed information can help us make the best match possible between your pet and family or rescue group.
16. Pet's Name:*
18. Breed (if unsure list what you think it may be mixed with)*
20. Pet's gender:*

    1. Male
    2. Female
22. Pet's age (use your best estimate)*
24. Is your pet fixed (sterilized/ altered)?*

    1. Yes
    2. No
    3. Unsure
26. If your pet has been fixed (sterilized/ altered), which clinic?
28. Where did you get your pet?*

    1. This shelter
    2. Another shelter
    3. Breeder
    4. Pet shop
    5. Friend/ Relative
    6. Found/ Stray
    7. Born at home
    8. Rescue group
30. If you received your pet from another shelter or rescue group, what is the name of the group or shelter?
32. How long have you had your pet?*
34. 
    
36. Where does your pet stay the majority of it's time?*

    1. Inside house
    2. Fenced yard
    3. Patio
    4. Unfenced yard
    5. Other
38. If other, please explain
40. Is your yard fenced?*

    1. Yes
    2. No
    3. I live in an apartment or living complex that does not have a yard provided
42. How high is the fence?
44. What is the fence made of (if unsure use best guess)?
46. What is the condition of the fence?
48. If yard is not fenced, how is pet confined outside?*
50. How many hours is the dog kept outside?*
52. How many hours is the dog kept inside?*
54. Where do you leave the pet when no one is home?*
56. How many hours a day does the dog spend unsupervised? *
58. How does your pet react to that time alone? *
60. Where does the pet sleep?*

    1. Owner's room
    2. Free roam of house
    3. Crate
    4. Doghouse
    5. Garage
    6. Other
62. If other, where?
64. What age group has the pet lived with? Select all that apply.*

    1. Adult Men
    2. Adult Women
    3. Seniors
    4. Children under 10
    5. Children under 16
66. How would you describe your pet around children? Check all that apply.*

    1. Friendly
    2. Playful
    3. Tolerant
    4. Afraid
    5. Snappy
    6. Too much for small children
    7. Never been with children
    8. Other
68. If other, please explain:
70. How does your pet react to strangers? Check all that apply.*

    1. Overprotective
    2. Anxious
    3. Fine
    4. Other
72. If other, please explain.
74. Does your pet have any fears? Check all that apply.*

    1. Being alone
    2. Thunderstorms
    3. Men
    4. Women
    5. Children
    6. Loud noises
    7. Hands
    8. Feet
    9. Large vehicles
    10. Appliances
    11. None
    12. Other
76. If other, please explain:
78. Does your pet have any negative behaviors? Check all that apply.*

    1. Chews objects
    2. Digs
    3. Food possessive
    4. Toy possessive
    5. Jumps fencing
    6. None
    7. Other
80. If other, please explain:
82. Does your pet have any positive behaviors? Check all that apply.*

    1. House trained
    2. Rides in cars well
    3. Leash trained
    4. Crate trained
    5. Obedience trained
    6. None
    7. Other
84. If other, please explain:
86. Does your pet know these basic commands? *

    1. Sit
    2. Stay
    3. Down
    4. Off
    5. Come
    6. Leave it
    7. Drop t
    8. Go to your crate/ bed
    9. None
    10. Other
88. If other, please explain:
90. If your pet is not house trained, when does he/she have accidents, and how often?
92. How does your pet ask to go outside? *
94. Do you supervise when pet is outside during that time?*

    1. Yes
    2. No
96. Does your pet escape?*

    1. Yes
    2. No
98. Has your dog repeatedly escape from the yard?*

    1. Yes, all the time
    2. Yes, when alone
    3. No
100. If so, how? Check all that apply.*

     1. Front door
     2. Backyard
     3. Digs
     4. Climbs fence
     5. Jumps fence
     6. Hole in fencing
     7. Does not escape
     8. Other
102. If other, please explain:
104. Has your pet been with other animals? *

     1. Yes
     2. No
106. Does the dog get along with other animals such as? Check all that apply.*

     1. Birds
     2. Dogs (male)
     3. Dogs (female)
     4. Cats (indoor)
     5. Cats (outdoor)
     6. Poultry/ Livestock
     7. None
     8. Other
108. If other, please explain:
110. Was your dog the leader of the group?
112. What types of animals does the dog not get along with? *
114. Has your pet shown any signs of aggression? Check all that apply.*

     1. Growls
     2. Snaps
     3. Lunges
     4. None
     5. Other
116. If other, please explain:
118. If pet has shown signs of aggression, what was the reason?
120. For any negative or aggressive behavior have you attempted training or had the dog examined?

     1. Yes
     2. No
122. Does your pet enjoy being groomed?*

     1. Yes
     2. No
     3. Has never been groomed
124. Does your pet tolerate having his/her nails clipped? *

     1. Yes
     2. No
     3. Has never had nails clipped
126. Does your pet have any likes?*
128. Does your pet have any dislikes?*
130. Does your pet have any special needs?
132. How often do you walk your dog?*
134. Health Info
136. Does your pet have any old injuries or health problems? If yes, please explain.*
138. Does your pet have any current health problems? If yes, please explain.*
140. Is your pet currently on medications? If yes, please list the medications.*
142. Has your pet had flea prevention medication within the past 30 days?*

     1. Yes
     2. No
144. Has your pet had heartworm prevention within the past 30 days?*

     1. Yes
     2. No
146. What type/brand of food does your pet eat? *
148. When was the dog usually fed?*

     1. AM
     2. PM
     3. Free fed
150. How much kibble is the dog usually fed at a feeding?
152. Any other information you’d like to provide?
154. Do you own any other animals? Check all that apply.*

     1. Dog(s)
     2. Cat(s)
     3. Other
     4. None
156. Veterinarian name or clinic name
158. Date of last visit/ shots
Leave This Blank:


159. Submit

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