Online Dog Surrender Form

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Dog Surrender Request

DOG 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 dog 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
Dog's Information
Dog's Name*
Dog's Age*
Dog's Sex*
- Male
- Female
- Unknown
Dog's Breed*
Why are you surrendering your dog?*
If we could help you solve this issue, would you be interested in keeping your dog?*
- Yes
- No
- Maybe
How long has your dog lived with you?*
Is your dog fixed?*
- Yes
- No
- Unknown
Is your dog microchipped?*
- Yes
- No
- Unknown
Is your dog part of a bonded pair?*
- Yes
- No
Name of dog bonded with:*
Upload current picture(s) of your dog*
Accepted file types: jpg, png, Max. file size: 32 MB.
Upload current picture(s) of your dog
Accepted file types: jpg, png, Max. file size: 32 MB.
Upload current picture(s) of your dog
Accepted file types: jpg, png, Max. file size: 32 MB.
Medical History
Is your dog up to date on their rabies vaccine?*
- Yes
- No
Date Given*
MM slash DD slash YYYY
Where?*
Is your dog up to date on their DA2PP vaccine?*
- Yes
- No
Date Given*
MM slash DD slash YYYY
Where?*
Is your dog up to date on their Bordetella vaccine?*
- Yes
- No
Date Given*
MM slash DD slash YYYY
Where?*
Name of your dog's veterinarian:*
Phone Number of your dog's veterinarian:*
When did your dog last see a veterinarian?*
Does your dog have any old injuries or health problems?*
- Yes
- No
- Not sure
Describe injuries or health problems*
Has your dog been diagnosed with and/or treated for any of the following? (Check all that apply):*
- Allergies
- Tumors
- Kennel Cough
- Heart murmur
- Epilepsy or seizure
- Organ Failure
- Thyroid Disease
- Urinary tract infection
- Diabetes
- Skin Condition
- Other
List other diagnosis or treatment*
Does your dog need any medication or special diet?*
- Yes
- No
Please list medications or special diet:*
Upload your dog's vaccination records:
Accepted file types: jpg, pdf, Max. file size: 32 MB.
Upload your dog's vaccination records:
Accepted file types: jpg, pdf, Max. file size: 32 MB.
Upload your dog's vet records:
Accepted file types: jpg, pdf, Max. file size: 32 MB.
Dietary Habits
What type of food was your dog fed? (Check all that apply):*
- Dry only
- Canned only
- Both dry and canned
- Other
Type of food fed:*
Brand of food your dog is used to:*
Is there any type of food your dog will not eat?*
- Yes
- No
Food your dog will not eat:*
What time of day was your dog fed? (Check all that apply):*
- AM
- PM
- Free Feed
Personality
How would you describe your dog's personality? (Check all that apply):*
- Very active
- Friendly to Family
- Aloof
- A clown
- Couch potato
- Shy to family or visitors
- Shy to visitors
- Playful
- Talkative
- Affectionate
- Independent
- Friendly to family or visitors
- Quiet
- Lap Dog
- Aggressive
- Withdrawn
- Feaful
- Fearless
- Solitary
Has your dog ever growled or snapped at anyone?*
- Yes
- No
Describe the circumstances:*
Has your dog ever bitten anyone?*
- Yes
- No
Did the bite break skin?*
- Yes
- No
Date of bite:*
Describe the bite circumstances:*
Where does your dog like to be petted?*
Where does your dog dislike to be petted?*
Is your dog frightened of anything? (Check all that apply):*
- Men
- Children
- Thunder
- Fireworks
- Vacuums
- Hands
- Feet
- Dogs
- Other
Describe what your dog is afraid of:*
How does your dog like to play? (Check all that apply):*
- Plays gently, does not usually use teeth
- Likes to play fetch
- Likes stuffed toys
- Gently plays with stuffed toys
- Rips and tears stuffed toys
- Prefers squeaky toys
- Likes to play with dogs
- Chases bugs or moths
- Likes to play in or around water
- Likes to learn tricks for treats
- Other
Describe how your dog likes to play:*
Does your dog have any favorite toys or activities?*
- Yes
- No
- Not sure
Describe your dog's favorite toys or activities:*
Lifestyle and Home Life
How much time was your dog kept outside?*
How much time was your dog kept inside?*
How many hours a day on average did your dog spend unsupervised?*
When left home alone, what did your dog have access to? (Check all that apply):*
- N/A - never left home alone
- Free roaming whole house
- Only a few areas
- Kept in a crate
- Other
What areas could your dog access when alone?*
What type of crate was your dog confined in?*
Describe areas your dog could access when alone:*
Where has your dog been allowed in/around your house? (Check all that apply):*
- Inside house
- Patio
- Fenced Yard
- Car
- Garage
Is your dog used to being allowed on: (Check all that apply):*
- Furniture
- Beds
- Only on floor
Where was your dog used to sleeping? (Check all that apply):*
- In owner's room
- In owner's bed
- Doghouse
- Garage
- Other
Describe where your dog is used to sleeping:*
How would you describe your household?*
- Active
- Noisy
- Quiet
- Average
What ages of people lived with your dog? (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 would you describe your dog's behavior around children? (Check all that apply):*
- Friendly
- Playful
- Tolerant
- Afraid
- Shy
- Aggressive
- Unknown
Describe how your dog reacts to visitors:*
Are there other animals in the home?*
- Yes
- No
What other animals were in the home with your dog? (Check all that apply):*
- Other dogs
- Cats
- Birds
- Other
List how many other dogs are in your home:*
What other types of animals has your dog lived with?*
How did your dog interact with other dogs? (Check all that apply):*
- Adored each other
- Slept near each other
- Avoided each other
- Groomed each other
- Afraid of each other
- Played with each other
- Peacefully coexisted
- Ignored each other
- Fought without injuries
- Fought with injuries
- Chased by other dog
- This dog chased the other dog
- Other
Describe how your dog interacted with other dogs in the home:*
What types of animals does your dog get along with? (Check all that apply):*
- Dogs (male)
- Dogs (female)
- Cats
- Birds
- Livestock
- Other
- Unknown
What other types of animals does your dog get along with?*
What types of animals does your dog NOT get along with? (Check all that apply):*
- Dogs (male)
- Dogs (female)
- Cats
- Birds
- Livestock
- Other
- Unknown
What other types of animals does your dog NOT get along with?*
Does your dog chase anything?*
- Yes
- No
Check all that apply:*
- People
- Children
- Cats
- Livestock
- Cars
- Bicycles
- Other
List other things your dog chases:*
Has your dog ever injured another animal?*
- Yes
- No
Describe the injury:*
Does your dog have any "bad" behaviors the new owners should be aware of?*
- Yes
- No
Describe these behaviors:*
Describe all you have done to correct the problem:*
What type(s) of training has your dog had? (Check all that apply):*
- Obedience Class
- Home Training
- Professional
- None
Does your dog know how to (Check all that apply):*
- Sit
- Stay
- Come
- Lie Down
- Walk on Leash
- None
- Other
Describe other commands or tricks your dog knows:*
Is your yard fenced?*
- Yes
- No
How do you keep your dog confined to your property?*
How high is the fence?*
What is the fence made of?*
Has your dog ever escaped from your yard?*
- Yes
- No
How did your dog escape? (Check all that apply):*
- Jumps fence
- Chews through fence
- Charges gate when opened
- Digs out
- Other
Describe how your dog has escaped before:*
Is your dog house trained/house broken?*
- Yes
- No
- Mostly
How often did your dog have accidents in the house? (Check all that apply):*
- Once a day
- Multiple times a day
- Once a week
- Never
- Every time inside house
What kind of potty training have you tried? (Check all that apply):*
- Potty pad
- Crate
- None
- Other
List other potty training methods:*
Is your dog accustomed to any of the following? (Check all that apply):*
- Bathing
- Nail trimming
- Ear Cleaning
- Brushing/Combing
Please list any additional information about your dog 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 dog and $20 per puppy.
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
Shelter and Main Offices
2115 Shelby Drive
Sedona, AZ 86336
Phone: 928-282-4679
PLEASE CALL AND MAKE AN APPOINTMENT TO SEE THE ANIMALS
10am to 4pm Daily

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