Pre-Relinquishment Questionnaire (Small Animal)

Pre-Relinquishment Questionnaire (Small Animal)

Please complete one form per pet.
Please complete the following questionnaire in advance of your scheduled appointment to surrender.

The purpose of this form is to collect important information about your pet's behavioral and medical history. It is important that the answers provided are honest and detailed. The information you provide will help us make the pet feel safe and secure in our care and aid in finding the best outcome for the pet, including placement options and matchmaking for adoptions.

You should submit one form per pet you are requesting to surrender to Lawrence Humane Society.

Once you have submitted your questionnaire, a staff member will review the information and may contact you if any additional information is needed.

If you have any questions, please call the Pet Resource Center at 785-371-0473 or help@lawrencehumane.org.

Thank you!
Name:

First Name of Owner or GuardianLast Name of Owner or Guardian
Preferred Name:
Name you wish to be called if different than above
Pronouns:

Other
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Preferred method of contact:
Preferred time of contact:
Preferred language:

Other
Have you used Lawrence Humane Society (LHS) services before or adopted a pet from LHS?
- Animal Name:
- Species:
  
  Other
- Please describe your amphibian:
- Please describe your reptile:
- Age and/or Birthday:
  Estimate if unsure
- Weight:
  Estimate if unsure
- Sex:
- Color(s):
- Distinguishing Markings:
- How long have you had your pet?
- What is the reason for needing to re-home your pet?
  
  Other
- Have you taken any steps to resolve or remedy the reasons that are causing you to re-home your pet?
- If yes, please describe:
- Are you interested in private re-homing as an alternative to surrendering your pet to the shelter?
- If we could provide you with any of the following resources, would you be able to keep your pet?
  
  Other
- Please describe what type of medical assistance:
- Has your pet been vaccinated in the last 12 months?
- Please list the Primary Veterinarian (name, clinic, and contact information) your pet sees, if any:
- Is your pet on any medications or special diet?
- If yes, please describe:
- Does your pet have any allergies or medical conditions?
- If yes, please describe:
- Where did you get your pet from?
  
  Other
- Please provide the name of the shelter or rescue your pet originated from:
- Where has your pet been living primarily?
  
  Other
- Are you willing to provide a cage, food and bedding at time of surrender?
- If yes, please describe the cage dimensions and the types of supplies you will be providing at time of surrender:
- What brand of food are you currently feeding your pet?
- Is your pet offered fruits and vegetables?
- If yes, how often and what types of fruits and/or veggies?
- Is your pet litter box trained?
- Does your pet like to be petted?
- How often do you trim your pet’s nails?
- What is the size of your pet’s cage or enclosure?
- How often is your pet provided time out of the cage?
- Has your pet lived with other animals?
- Please list the other types of animal(s) your pet has lived with, and describe their interaction(s):
- What types of people has your pet lived with?
  
  Other
- How would you best describe your pet’s personality most of the time?
- Please tell us your pet's "bad habits". If there aren't any, enter "none".
- Please tell us something interesting, unique or fun about your pet, his/her traits, or personality that we can tell potential adopters:
- Is there any other information you would like us to know about your pet that may help us find the best placement options for this animal?
- Other information for best placement options:
- I am the owner or authorized agent/designee for the owner of the animal described above.
- The information provided in this questionnaire is accurate and true to the best of my knowledge.
- Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Should be Empty: