Cat Surrender – Larimer Humane Society

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Cat Surrender Form

Step 1 of 9

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General History
Why are you surrendering your cat today?*
If we could help you resolve the issues surrounding the surrender of your pet, would you be interested in keeping your animal?*
- No
- Yes
Please stop and contact us at (970) 226-3647 ext. 0

Owner Information
Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIp
Phone
Email

General History
Cat's Name:*
Cat's nickname:
Age or approximate age:
How old was this cat when you acquired him/her?
Breed:
Color:
Sex:*
- Male
- Female
- Unknown
Has this cat been spayed or neutered?*
- No
- Yes
- Unknown
Has this cat been microchipped?*
- No
- Yes
- Unknown
Microchip Number:
How long have you owned this cat?
Including your home, how many homes has this cat had?
Where did you acquire this cat?
- Larimer Humane Society
- Friend/Relative
- Found as stray
- Pet store
- Born in my home
- 'Free to good home' ad
- Other
Other place:

Medical History
Did this cat receive annual exams by a veterinarian?*
- No
- Yes
- Unknown
Is this cat current on his/ her rabies vaccination?*
- No
- Yes
- Unknown
Does this cat have any medical problems or previous injuries that require special attention or a special diet?*
- No
- Yes
- Unknown
Please check all conditions that your cat has been diagnosed with or has been treated for:
- Allergies
- Urinary tract infection (UTI)
- Upper respiratory infection
- Epsilepsy/Seizures
- Thyroid Disease
- Skin Problems
- Ringworm
- Diabetes
- Liver disease
- Kidney disease
- Heart murmur
- Heart Worms
- Obesity
- FIV
- Other
Other condition:

Litter Box Habits
Often a change in environment (family move, new pet, new baby, change of litter type) can cause a cat to use the litter box inconsistently. Please provide us with as much detail as possible regarding your cat’s litter box habits. Sometimes litter box issues are the signs of health or behavioral problems (mild or serious) that may be modified or eliminated with treatment from your veterinarian.
Did your cat have access to a litter box in the house?
- No
- Yes
What type of litter box was provided?
- Covered
- Uncovered
- Automatic Scooping
How many litterboxes?
What type of litter was used?
- Scented
- Unscented
- Clumping
- Non Clumping
- Clay
- Pine
- Alfalfa
- Crystals
- Yesterday's News
- Other
Please explain:
How often did you scoop the litter box?
- Daily
- Every few days
- Weekly
- Rarely
Did your cat use the litter box?
- No
- Yes-consistently
- Sometimes

Dietary Habits
What brand of food does this cat eat?*
- Premium brand (Science Diet, Eukanuba)
- Grocery store brand (9-lives, Friskies)
- Generic brand (Sam’s brand, Dollar Store)
- Home cooked diet
- Prescription Diet
Which of the following does your cat eat?*
- Dry food only
- Canned food only
- Combination of dry and canned
- Table scraps
- Home cooked diet
- Other
Other diet:
Do you feed your cat treats?
- No
- Yes
What kind?
How often is this cat fed?*
- Once daily
- Twice daily
- Food always available
- Other
Please explain:

Personality Profile
What traits best describe your cat's personality (check all that apply)
- Very energetic
- Talkative
- Shy to strangers
- Shy with some family members
- Playful
- Friendly/affectionate to family members
- Independent
- Affectionate
- Lap dog - loves attention
- Fearful
- A loner
- Stubborn
- Lazy - couch potato
- Other
Please explain:
What traits best describe your cat's personality (check all that apply)
- Very gentle
- Enjoys playing hide-and-seek
- Likes to play with other cats
- Likes to play with dogs
- Will learn tricks for treats
- Very energetic and rambunctious
- Doesn't show a great interest in playing
- Like to play chase or pounce with certain toys
- Other
Trait not listed:

Lifestyle and Home Life
Was this cat (check all that apply)
- Indoors
- Outdoors
- Indoors in cold weather
- Out during the day, in at night
- In the garage or basement
- Other
Please explain:
If indoor only, does the cat try to escape?
- Yes
- No
Did this cat have access to?
- All areas of the home
- Certain rooms only
- Other
Please explain:
Does this cat live with/have normal interaction with? (check all that apply)
- Cats
- Dogs
- Children
- None of the above
This cat seems most comfortable with
- Men
- Women
- Senior Citizens
- Children
- Teenagers
- Other animals
- Loves everyone!
What is your cat afraid of? (check all that apply)
- Thunderstorms
- Loud noises
- Vacuums
- Being alone
- Men
- Women
- Children
- Strangers
- Fast movement
- Car rids
- Restraint
- Crates
- Dogs
- Cats
- Vet
- Other
If you checked any of the above, please elaborate:
Does your cat have any areas of sensitivity where he/she does not like to be touched?
- No
- Yes
Please describe areas and cat's reaction

Additional Information
Please free to add additional comments that you think would be helpful to shelter staff or potential adopters

Call us:
970.226.3647

Visit us:
3501 E 71^st Street
Loveland, CO 80538

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