Online Small Critter Surrender Form

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Small Critter Surrender Request

SMALL CRITTER SURRENDER FORM
Date of Request*
MM slash DD slash YYYY
Owner's Information
Owner Name:*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email :*
Phone:*
Is texting OK?*
- Yes
- No
By checking YES above, you agree to receive recurring messages from Humane Society of Sedona; Reply STOP to opt out; Reply HELP for help; Message frequency varies; Message and data rates may apply; Carriers are not liable for delayed or undelivered messages
Are You a Sedona Resident?*
- Yes
- No
Have You Reached out to Your Local Shelter?*
- Yes
- No
Name of Shelter You Reached Out To:*
What have you done so far to rehome your pet on your own? (Check all that apply):*
- Select All
- Social Media
- Flyers
- Friends
- Family
- Coworkers
- HSS Courtesy Post
- Adopt A Pet.com Profile
- Next Door
- Home-to-Home Profile
- None of the Above
- Other
Small Critter's Information
Pet's Name*
Pet's Age*
Pet's Sex*
- Male
- Female
- Unknown
Pet's Species*
Why are you surrendering your pet?*
If we could help you solve this issue, would you be interested in keeping your pet?*
- Yes
- No
- Maybe
How long has your pet lived with you?*
Is your pet fixed?*
- Yes
- No
- Unknown
Is your pet microchipped?*
- Yes
- No
- Unknown
Is your pet part of a bonded pair?*
- Yes
- No
Name of pet bonded with:*
Upload current picture(s) of your pet*
Accepted file types: jpg, png, Max. file size: 32 MB.
Upload current picture(s) of your pet
Accepted file types: jpg, png, Max. file size: 32 MB.
Upload current picture(s) of your pet
Accepted file types: jpg, png, Max. file size: 32 MB.
Waste Management Habits
Does your pet use a litter box?*
- Yes
- No
Did they use it with success?*
- Yes
- No
- Sometimes
Where does your pet go potty?*
How often does your pet make mistakes?*
Please describe the accidents (Check all that apply):*
- Urinates outside of the box
- Urinates on clothing/furniture
- Poops outside of the box
- Sprays on walls/furniture
- All of the Above
- Other
Describe accidents:*
If litter box accidents were an issue, when did they begin?*
- Past Month
- Past Year
- Ongoing
- N/A
Can you pinpoint any changes in your household event(s) that might have influenced or triggered inappropriate litter box use? Please describe:*
Please describe what measures you have taken to correct this problem:*
Has your pet been examined by a veterinarian to rule out physical problems?*
- Yes
- No
What was the outcome?*
How often was the litter box scooped?*
- Everyday
- Every few days
- Weekly
- Rarely
What type(s) of litter was used? (Check all that apply):*
- Unscented
- Scented
- Clumping
- Non-Clumping
- Crystals
- Clay
- Pine
- Newpaper
- Other
Litter used:*
What type(s) of litter box was used? (Check all that apply):*
- Covered
- Uncovered
- Self-Cleaning
How many litter boxes are in your home?*
Where are the litter boxes located?*
Medical History
Has your pet had a rabies vaccination?*
- Yes
- No
Date Given*
MM slash DD slash YYYY
Where?*
Has your pet had any other vaccinations?*
- Yes
- No
Which ones?*
Date Given*
MM slash DD slash YYYY
Where?*
Name of your pet's veterinarian:*
Phone Number of your pet's veterinarian:*
When did your pet last see a veterinarian?*
Does your pet have any old injuries or health problems?*
- Yes
- No
- Not sure
Describe injuries or health problems*
Has your pet been diagnosed with and/or treated for any of the following? (Check all that apply):*
- Allergies
- Tumors
- Upper Respiratory Infection
- Heart murmur
- Epilepsy or seizure
- Organ Failure
- Thyroid Disease
- Urinary tract infection
- Diabetes
- Other
Describe other diagnosis or treatment*
Does your pet need any medication or special diet?*
- Yes
- No
Please list medications or special diet:*
Upload your pet's vaccination records:
Accepted file types: jpg, pdf, Max. file size: 32 MB.
Upload your pet's vet records:
Accepted file types: jpg, pdf, Max. file size: 32 MB.
Dietary Habits
What type of food was your pet fed? (Check all that apply):*
- Dry only
- Canned only
- Both dry and canned
- Other
Type of food fed:*
Brand of food your pet is used to:*
Is there any type of food your pet will not eat?*
- Yes
- No
Food your pet will not eat:*
Personality
How would you describe your pet's personality? (Check all that apply):*
- Very active
- Friendly to Family
- Aloof
- A clown
- Couch potato
- Shy to family or visitors
- Playful
- Talkative
- Affectionate
- Independent
- Friendly to family or visitors
- Quiet
- Lap cat
- More like a dog
- Withdrawn
- Playful
- Fearful
- Fearless
- Solitary
Has your pet ever bitten anyone?*
- Yes
- No
Did the bite break skin?*
- Yes
- No
Date of bite:*
Describe the bite circumstances:*
Does your pet use a scratching post?*
- Yes
- No
- Doesn't have one
Where does your pet like to be petted?*
Where does your pet dislike to be petted?*
Is your pet frightened of anything? (Check all that apply)*
- Men
- Children
- Thunder
- Fireworks
- Vacuums
- Hands
- Feet
- Dogs
- Other
Describe what your pet is afraid of:*
How does your pet like to play? (Check all that apply):*
- Plays gently, does not usually use teeth or claws
- Likes to play hide and seek
- Likes to chase and pounce with a variety of toys
- Likes to play with other animals
- Likes to play rough, may bite or scratch
- Not much interest in play
- Likes things that crackle, such as paper bags
- Likes to play with dogs
- Will fetch items such as bottle caps or toys
- Chases bugs or moths
- Likes to play in or around water
- Likes to learn tricks for treats
- Other
Describe how your pet likes to play:*
Does your pet have any favorite toys or activities?*
- Yes
- No
- Not sure
Describe your pet's favorite toys or activities:*
Lifestyle and Home Life
What ages of people lived with your pet? (Check all that apply):*
- Adult Men
- Adult Women
- Seniors
- Older Children (8+ years)
- Younger Children (7 years and under)
Please list ages of children:*
How did your pet interact with young children (under age 7)? (Check all that apply):*
- Pet actively avoided child
- Pet & child played together
- Pet & child ignored each other
- Child could pet our pet
- Pet hissed or growled at child
- Mutual adoration
How would you describe your pet's behavior around children in general? (Check all that apply):*
- Friendly
- Playful
- Tolerant
- Afraid
- Shy
- Aggressive
- Unknown
Is your pet most comfortable with: (Check all that apply):*
- Women
- Men
- Kids
- Teenagers
- Seniors
- Loves all people
Describe how your pet reacts to visitors:*
Are there other animals in the home?*
- Yes
- No
List how many other animals in your home:*
What other animals were in the home with your pet? (Check all that apply):*
- Cats
- Dogs
- Birds
- Other
What other types of animals has your pet been around?*
How did your pet interact with cats? (Check all that apply):*
- Adored each other
- Slept near each other
- Ignored each other
- Rough with each other
- Played together
- Fought without injuries
- Peacefully coexisted
- Gentle with each other
- Sniffed noses
- Groomed each other
- Fought with injuries
- Caused this cat stress
- Other
Describe how your pet interacted with cats in the home:*
How did your pet interact with dogs in the home? (Check all that apply):*
- Groomed each other
- Cat rubbed on dog
- Played with each other
- Peacefully coexisted
- Gentle with each other
- Sniffed Noses
- Fought without injuries
- Dog chased cat
- Cat tormented dog
- Cat feared dog
- Fought with injuries
- Caused this cat stress
- Other
Describe how your pet interacted with dogs in the home:*
Describe how your pet interacted any other animals: livestock, reptiles, fish, etch:*
How would you describe your household?*
- Active
- Noisy
- Quiet
- Average
What areas of your home did your pet have access to? (Check all that apply):*
- Inside only
- Inside with access to outside
- Outside only
- Inside at night
- Garage or Basement
- In barn or shed
- Screened porch
- Indoors in cold weather
- Outdoors in warm weather
- Other
Describe your pet's living area:*
Does your pet do any of the following? (Check all that apply):*
- Jump on counters/tables
- Scratch furniture
- Chew plants
- Climb curtains
- Chew personal items
- Scratch doors/cabinets
- Other
Describe any other behaviors your pet may have:*
Is your pet accustomed to any of the following? (Check all that apply):*
- Bathing
- Nail trimming
- Ear Cleaning
- Brushing/Combing
Please list any additional information about your pet that you would like us to know:
Acknowledgement & Agreement*

By checking this box, I acknowledge, understand, and agree to the following:
1. I am legal the owner of this animal.
2. The placement of an individual animal for adoption is based on an evaluation of his or her health and temperament.
3. HSS cannot guarantee the rehoming of my pet and that once an animal is placed up for adoption at HSS, there is no time limit in which he or she can remain up for adoption.
4. The surrender fees are $75 per adult critter and $20 per juvenile critter.
5. The disposition of my animal is left entirely to the discretion of HSS and will in no way hold HSS responsible for the final disposition of the animal upon surrender.
6. I relinquish the right to obtain any information about this animal as well as any claims to this animal upon surrender.
Owner's E-Signature*

Humane Society of Sedona

Humane Society of Sedona
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Sedona, AZ 86336
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