Which of the following reasons would you give up your pet:    Please check all that apply:
    Moving:
             Divorce:              Not Good with Children:
   
Aggressive:
            Shedding:
            Not Staying in Fence:
    Financial Reasons:
        New Baby:         Excessive Barking:
   
Adult Size Too Large:
        Not Getting Along with Other Pets:
    Other (Please Explain): 
Have you ever turned in a pet to the animal shelter?   Yes    
No
     If yes, why: 
Has a pet died while living in your care?   Yes    
No
     If yes, explain:  
Do you currently own a pet?   Yes    
No
If yes, how many?       Types:
     Do your pets live:   Inside?           Outside?           Both?
      Are your current pet(s) shots up to date?  Yes    
No
     Are your current pet(s) spayed/neutered?  Yes    
No
      If not, why? 
     Are your current pet(s) on heartworm preventative?  Yes    
No
      If yes, what is the name of the preventative?  
      If not, why?  
      What is your current vets name and phone number:  
      What is the name of animal(s) seen there: 
      Do you mind if we call your vet for a reference?   Yes    
No
  
Signature:                   Date: