Small Animal Surrender Form | Mohawk Hudson Humane Society

Client Information

First and Last Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone

Ext:

Alternate Phone

Ext:

Veterinarian Name

Clinic/Practice Name

Clinic/Practice Phone Number

If applicable, is this animal up-to-date with a rabies vaccination?

Yes

No

Not Applicable

Date of last rabies vaccination:

Please list any medication and dosage this animal currently receives (including supplements):

Has this animal ever had serious medical issues?

Yes

No

If yes, please explain:

Describe this animal's behavior while at the veterinarian (ex. is medication needed):

This information will help us determine what type of home will be best for this animal in the future.

What brand of small animal food is fed to this animal?

How much and at what time(s) is this animal fed?

What is this animal’s favorite treat?

Describe a typical 24-hour day in this animal's life:

Does this animal go outside?

Yes

No

Not on purpose

How often and how far from your home does this animal go?

What is this animal's favorite type of toy?

Describe the housing type in which this animal lives (cage, room, enclosure, etc.):

Check this box in acknowledgement of the $45 surrender fee to help offset care of this small animal if accepted into the Adoption Program.