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Cat Surrender Form
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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
Email
This field is for validation purposes and should be left unchanged.
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