Online Cat Surrender Form

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Cat Surrender Request

CAT 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 cat 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
Cat's Information
Cat's Name*
Cat's Age*
Cat's Sex*
- Male
- Female
- Unknown
Cat's Breed*
Why are you surrendering your cat?*
If we could help you solve this issue, would you be interested in keeping your cat?*
- Yes
- No
- Maybe
How long has your cat lived with you?*
Is your cat fixed?*
- Yes
- No
- Unknown
Is your cat microchipped?*
- Yes
- No
- Unknown
Is your cat part of a bonded pair?*
- Yes
- No
Name of cat bonded with:*
Is your cat declawed?*
- Yes
- No
Front only or all four declawed?*
Is your cat a feral or community cat?*
- Yes
- No
Upload current picture(s) of your cat*
Accepted file types: jpg, png, Max. file size: 32 MB.
Upload current picture(s) of your cat
Accepted file types: jpg, png, Max. file size: 32 MB.
Upload current picture(s) of your cat
Accepted file types: jpg, png, Max. file size: 32 MB.
Litter Box Habits

We get asked so many questions about litter box use because it is one of the main reasons cats are surrendered. Please help us by giving as much detailed information as possible. Some changes in environment may be just what the cat needs, and sometimes there are more serious health or behavioral issues involved.
Did your cat have access to a litter box in the house?*
- Yes
- No
- Sometimes
Did your cat use the litter box?*
- Yes
- No
- Sometimes
How often does your cat 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? (Check all that apply):*
- 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 cat been examined by a veterinarian to rule out physical problems?*
- Yes
- No
What was the outcome?*
Did your cat use the bathroom only outdoors?*
- Yes
- No
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
Is your cat up to date on their rabies vaccine?*
- Yes
- No
Date Given*
MM slash DD slash YYYY
Where?*
Is your cat up to date on their FVRCP vaccine?*
- Yes
- No
Date Given*
MM slash DD slash YYYY
Where?*
Has your cat been tested for FIV?*
- Yes
- No
Date tested:
MM slash DD slash YYYY
Result?*
Has your cat been tested for FeLV?*
- Yes
- No
Date tested:*
MM slash DD slash YYYY
Result?*
Name of your cat's veterinarian:*
Phone Number of your cat's veterinarian:*
When did your cat last see a veterinarian?*
Does your cat have any old injuries or health problems?*
- Yes
- No
- Not sure
Describe injuries or health problems*
Has your cat 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 cat need any medication or special diet?*
- Yes
- No
Please list medications or special diet:*
Upload your cat's vaccination records:
Accepted file types: jpg, pdf, Max. file size: 32 MB.
Upload your cat's vet records:
Accepted file types: jpg, pdf, Max. file size: 32 MB.
Dietary Habits
What type of food was your cat fed? (Check all that apply):*
- Dry only
- Canned only
- Both dry and canned
- Other
Type of food fed:*
Brand of food your cat is used to:*
Is there any type of food your cat will not eat?*
- Yes
- No
Food your cat will not eat:*
Personality
How would you describe your cat'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 cat ever bitten anyone?*
- Yes
- No
Did the bite break skin?*
- Yes
- No
Date of bite:*
Describe the bite circumstances:*
Does your cat use a scratching post?*
- Yes
- No
- Doesn't have one
Where does your cat like to be petted?*
Where does your cat dislike to be petted?*
Is your cat frightened of anything? (Check all that apply):*
- Men
- Children
- Thunder
- Fireworks
- Vacuums
- Hands
- Feet
- Dogs
- Other
Describe what your cat is afraid of:*
Is your cat a hunter?*
- Yes
- No
- Don't know
How does your cat 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 cats
- 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 cat likes to play:*
Does your cat have any favorite toys or activities?*
- Yes
- No
- Not sure
Describe your cat's favorite toys or activities:*
Lifestyle and Home Life
What ages of people lived with your cat? (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 cat interact with young children (under age 7)? (Check all that apply):*
- Cat actively avoided child
- Cat & child played together
- Cat & child ignored each other
- Child could pet cat
- Cat hissed or growled at child
- Mutual adoration
How would you describe your cat's behavior around children? (Check all that apply):*
- Friendly
- Playful
- Tolerant
- Afraid
- Shy
- Aggressive
- Unknown
Describe how your cat reacts to visitors:*
Are there other animals in the home?*
- Yes
- No
What other animals were in the home with your cat? (Check all that apply):*
- Other cats
- Dogs
- Birds
- Other
List how many other cats are in your home:*
How did your cat interact with other 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 cat interacted with other cats in the home:*
How did your cat 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 cat interacted with dogs in the home:*
What other types of animals has your cat been around?*
Describe how your cat interacted with other animals: livestock, reptiles, fish, etch:*
How would you describe your household?*
- Active
- Noisy
- Quiet
- Average
What areas of your home did your cat 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 cat's living area:*
Does your cat 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 cat may have:*
Is your cat accustomed to any of the following? (Check all that apply):*
- Bathing
- Nail trimming
- Ear Cleaning
- Brushing/Combing
Please list any additional information about your cat that you would like us to know:
Acknowledgement & Agreement*

By checking this box, I acknowledge, understand, and agree to the following:
1. I am the legal 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 cat and $20 per kitten.
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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2115 Shelby Drive
Sedona, AZ 86336
Phone: 928-282-4679
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