Dog Surrender – Larimer Humane Society

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Dog Surrender Form

Step 1 of 8

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General History
Why are you surrendering your dog 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
Dog's Name:*
Dog's nickname:
Age or approximate age:
How old was this dog when you acquired him/her?
Breed:
Color:
Sex:*
- Male
- Female
- Unknown
Has this dog been spayed or neutered?*
- No
- Yes
- Unknown
Has this dog been microchipped?*
- No
- Yes
- Unknown
Microchip Number:
How long have you owned this dog?
Including your home, how many homes has this dog had?
Where did you acquire this dog?
- 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 dog receive annual exams by a veterinarian?*
- No
- Yes
- Unknown
Is this dog current on his/ her rabies vaccination?*
- No
- Yes
- Unknown
Does this dog have any medical problems or previous injuries that require special attention or a special diet?*
- No
- Yes
- Unknown
Please check all conditions that your dog has been diagnosed with or has been treated for:
- Allergies
- Urinary tract infection (UTI)
- Kennel Cough
- Epilepsy/Seizures
- Thyroid Disease
- Skin Problems
- Ringworm
- Diabetes
- Liver disease
- Kidney disease
- Heart murmur
- Heart Worms
- Obesity
- Parvovirus
- Other
Other condition:

Dietary Habits
What brand of food does this dog 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 dog eat?*
- Dry food only
- Canned food only
- Combination of dry and canned
- Table scraps
- Home cooked diet
- Other
Other diet:
Do you feed your dog treats?
- No
- Yes
What kind?
How often is this dog fed?*
- Once daily
- Twice daily
- Food always available
- Other
Please explain:

Personality Profile
What traits best describe your dog'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 dog's personality (check all that apply)
- Very gentle
- Enjoys playing fetch
- Likes to play with other dogs
- Likes to play with cats
- Will learn tricks for treats
- Very energetic and rambunctious
- Doesn't show a great interest in playing
- Like to play with toys
- Other
Trait not listed:

Lifestyle and Home Life
Was this dog (check all that apply)
- Indoors except to potty
- Outdoors during the day, in at night
- Outside 24 hours
- In and out throughout the day
This dog sleeps (check all that apply)
- Inside, on the floor
- Inside, on a dog bed
- Inside, on a chair or sofa
- Inside, in bed with adults
- Inside, in bed with children
- In a crate
- In a garage or barn
- Outside, in a dog house
- Outside, on ground or under porch
Is this dog housebroken? (check all that apply)
- Yes, completely
- No, has frequent accidents
- Mostly, has occaional accidents
- Only has accidents while left alone for long periods
- Accidents are urine only
- Accidents are bowel movements only
While outside, my dog is: (check all that apply)
- No confinement, allowed to run loose
- 6' - 8' privacy fence
- 3' - 4' chain link fence
- Fenced run
- Confined in garage
- Tethered by chain or cable
Have you had any problems keeping this dog confined? (check all that apply)
- No, stays in yard
- Yes, jumps fence
- Yes, digs to get out
- Other
Please explain:
Is this dog ever crated? (check all that apply)
- No
- Yes, for car rides
- Yes, when left alone
- Yes, during the day
- Yes, overnight
What kinds of exercise did this dog receive? (check all that apply)
- Daily walk, on lead
- Placed on cable or run outside
- Walked 1-3 times per week, on lead
- Put out in fenced yard
- No regular exercise period
- Taken to off-leash park or the country to run loose
Has this dog regularly been around children?
- No
- Yes
How old were the children?
How does this dog behave around adults?
- Submissive
- Playful
- Calm
- Avoids adults
- Play gets out of control
- Protective
- Aggressive
- Aloof
- Easygoing
- Fearful
- Friendly
- Nervous
- Quiet
- Shy
- Noisy
Describe how this dog behaves when people come to visit. (check all that apply)
- Quiet
- Excited or friendly
- Barks at doorbell or knocking at the door
- Runs and hides, doesn't come out
- Barks at people once they are inside
- Jumps up on them
- Continually pesters visitors for attention
- Starts out unsure, then gradually warms up and is friendly
- Protective, growls when visitors reach toward a family member
- Other
Please explain:
How does this dog behave around other dogs? (check all that apply)
- Never been around other dogs
- Friendly, no fighting
- Fight over certain situations or possessions
- This dog picked on other dogs
- Stiff, nervous
- Other dogs picked on this dog
- Didn't really care, avoided other dogs
- Did not get along at all, constantly fought
- Other
Please explain:
How does this dog behave around cats? (check all that apply)
- Never been around other cats
- Friendly, no fighting
- Fight over certain situations or possessions
- This dog picked on other cats
- Stiff, nervous
- Cats picked on this dog
- Didn't really care, avoided other cats
- Did not get along at all, constantly fought
- otherd
Please Explain
My dog knows: (check all that apply)
- Sit
- Stay
- Come
- Down
- Heel
- Shake
- Fetch
- Other
Please explain:
How does this dog behave on leash? (check all that apply)
- Has experience, walks calmly, no pulling
- Pulls occasionally, but mostly does well
- Pulls constantly
- Fights the leash, bites and struggles
- No experience on leash
What is your dog 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
Please explain:
How is this dog disciplined? (check all that apply)
- Yelling, scolding
- Body gestures, arms waving, etc.
- Locked away for time-out
- Thrown outside
- Physically taken over to mess, nose rubbed in it
- Discipline handed out when the mess is found
- Ignore it, clean up mess, try to catch the dog in the act to teach corrective behavior
- Physical contact, hitting, kicking
Does this dog have any of the following behaviors that you consider a problem? (check all that apply)
- Barks too much
- Jumps fences
- Runs away when escape
- Chews up household items
- Chews up plants or outdoor structures
- Unable to housetrain
- Sprays/marks with urine inside house
- Separation anxiety
- Digging
- Too bold and rough to deal with, nips during play
- Growls or bites when food, treats or toys are present
- Jumps up on people
- Under foot constantly
- Insecure, too needy
- Aggressive with strangers
- Aggressive with children
- Unpredictable, becomes aggressive for no reason
- Aggressive toward other animals
- Kills other animals
- Fearful
- Other
Please explain:
If you checked any of the above, please elaborate:
Has this dog ever been aggressive towards people or animals? (check all that apply)
- Yes, has attacked or bit people
- Yes, has attacked or bit other dogs
- Yes, has attacked or bit other animals
- Yes, has growled at or lunged at people
- Yes, has growled at or lunged at dogs
- Yes, has growled at or lunged at other animals
- No, has shown no aggression towards animals or people

Additional Information
Please free to add additional comments that you think would be helpful to shelter staff or potential adopters
Phone
This field is for validation purposes and should be left unchanged.

Call us:
970.226.3647

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

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