Please answer all questions truthfully and completely. This will help us find the best home for your pet. The answers will not count against you or the animal but help prevent an animal from being misplaced a second time.

Pet Name:

Age/Birthdate:

Breed:

Color/Markings:

Have you had this dog/cat since it was a puppy/kitten? _________ If no where did you get it? _________________________ At what age: __________

Is the animal good with dogs? _________________ cats? _________________

kids? __________ what age group(s) ___________________________________

Spayed/Neutered: ________ Date: ________ Vet: ______________________

Shots/Dates: _________________________________________________________

Preventatives Used: ______________________________ Dates: ____________

Checked for heart worm or lyme disease? ________ If yes, when? _______

Checked for feline leukemia ? ___________ If yes when? ________________

Medications or medical conditions: ____________________________________

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Is the dog obedience trained? _____ Knows commands? ________________

House trained/litter box trained? _____

What kind of food do you use? ____________________ Treats? ___________

Are there any special dietary needs? ___________________________________

Is pet crate trained? _____ How many hours a day is pet left unattended? ______________________ Where is it kept? ______________________________

Is your home: noisy ______ active ______ quiet ______ average ______

Cats: Is cat declawed? _____ Does cat go outdoors? _____ Does the cat claw furniture? _____ Bite? _____ Is the cat social and likes to be held or a loner that comes for attention on his/her terms? _____________________

Does it allow you to brush him/her? _____ Afraid of anything? _________

If yes, what? ______________________________ Personality traits _________

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Dogs: Does your pet chew? _____ Jump up? _____ Barks/howl? ______

Nip/Bite? _____ If yes under what circumstances? _____________________

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Possessive of toys? ________ Bones? ________ Does it chase cars or other animals? ________________________ Dig? _____ Ride in car? ____________

Like swimming/water? __________ Does dog allow you to brush it? ____

Wash it? ______ Clip nails? _____ Is dog frightened by anything? ______
If yes, what? __________________________________________________________

Personality traits ______________________________________________________

What type of home would best suit your pet? ___________________________

________________________________________________________________________

The reason for relinquishing this pet: __________________________________

________________________________________________________________________

I state that at no time did this pet exhibit aggression or viciousness toward a human being or another animal other than what has been disclosed to Safe Haven. ________ (Initial)

I hereby relinquish all claims and ownership of said pet to Safe Haven and/or a representative. After I have signed this agreement I cannot reclaim this pet.

I agree to give Safe Haven all paperwork and medical records and any other relevant materials pertaining to this pet.

I have disclosed all medical, physical or hereditary problems that are known to me at the time of relinquishment.

I verify that all statements are true and accurate according to my knowledge.

Signature: ____________________________________________________________

Address: ______________________________________________________________

Phone: _______________________________ Date: _________________________

Email address: ________________________________________________________

Safe Haven volunteer: _________________________________________________

If your animal exhibits aggression of any form towards humans or other animals the animal will be returned to you and we will refund any donation made. We cannot take aggressive pets into our rescue. If this is a recurring problem, the option of euthanasia is to be handled by you and not Safe Haven.