2010 Arcadia Street
Fort Myers, Florida 33916
Office: (239) 332-0364 Fax: (239) 332-8676
PET BACKGROUND FORM
Pets Name____________________________ Species______________ Breed_____________ Color____________
Age or Date of Birth_______________________ Sex_______ Altered _____________ Declawed______________
Why are you surrendering your pet? ______________________________________________________________
____________________________________________________________________________________________
How long have you had your pet? __________. Where did you acquire your pet? __________________________
Is your pet current on heartworm & flea prevention? ________ . What brand? ____________________________
When was it given last? ________________________________________________________________________
What brand of food does your pet eat? ____________________________. How often______________________
Does your pet have any current or past health conditions or injuries? ____________________________________
_____________________________________________________________________________________________
Who does your pet get along with? Please circle Men Women Children (ages) _____ Dogs Cats Other animals
Does your pet live indoor, outdoors or both? ________________. Where does your pet sleep? _________________
Has your pet ever shown signs of aggression such as biting, snapping , growling, food aggression, aggression towards
animals, aggression towards people or children?________________________________________________________
If yes, was the aggression provoked? Please explain_____________________________________________________
Does your pet have any bad habits such as digging, fence jumping, scratching furniture, chewing, barking or jumping
on people?_____________________________________________________________________________________
Is your pet house trained or litter trained? ____________________________________________________________
Does your pet allow you to.....? (Circle all that apply) Trim nails/ grooming/ clean ears/ Bath Brush Teeth
Does your pet have any obedience training? ____________ Does your pet know any commands? ________________
Please tell us about your pet and any special characters, personality traits, or special needs_____________________
_______________________________________________________________________________________________
PET INTAKE FORM
Owner Name_______________________________________________________Date___________________
Address__________________________________________ City __________________ State_____ Zip______
Phone Number_________________________________ Alternate Number____________________________
Pets Name _______________________ Species _______________ Breed ________________ Color__________
Age or DOB ______________________ Sex __________ Altered ____________ Declawed _______________
Eye Color ________________ Distinguishing Marks _____________________ Microchip _________________
Pattern:
(Please Circle) Bi-color Tri-color Calico Brindle Dilute Harlequin Merle Point Roan
Salt/Pepper Solid Spotted Tabby Tick Tortoiseshell Tuxedo
Coat:
(Please Circle) Short Medium Long Wiry Curly Smooth Silky Wavy
Ears:
(Please Circle) Cropped Droopy Erect Long Notched Semi-erect Tipped
Tail:
(Please Circle) Bob Curled Docked Kinked Long Missing Short
Owner Surrender___________________ Stray _________________ Return _______________________
Statement of Surrender
I certify that I do ___ /do not ____ own the animal described above and hereby surrender all interest to the Gulf Coast Humane
Society. My interest in this animal has now been voided and I will not be given any information on the welfare or disposition of
this animal. Initials _____________
There is no minimum set time for holding this animal. The holding time depends on the animal’s health, behavior, and
adoptability. It is also agreed that neither said society nor its management and employees shall incur any obligation to me on the
disposition of the above listed animal. I certify that this animal has not bitten another animal or humane within the last 10 days.
Initials_______________
I have read and understand that I have surrendered my rights and interest towards this animal.
Signature__________________________________________ Date __________________
I would like to make a donation in the amount of $_____________ to the Gulf Coast Humane Society to assist I the care of the
animals in need.
Signature_____________________________________________ Date___________________
2010 Arcadia Street
Fort Myers, Florida 33916
Office: (239) 332-0364 Fax: (239) 332-8676