Dog Surrender – Larimer Humane Society

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Dog Surrender Form

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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

Call us:
970.226.3647

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

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