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Feline Surrender Form
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* Indicates required question
Email
*
Your email
Cat's Name
Your answer
Cat's Age
Your answer
Date of Birth
MM
/
DD
/
YYYY
Cat's nickname
Your answer
Gender
Male
Female
Clear selection
Breed
Your answer
Spayed/Neutered?
yes
no
Clear selection
Declawed?
yes
no
Clear selection
MEDICAL HISTORY
Vet Office Name/Location
Your answer
Has your cat ever had surgery?
yes
no
unknown
Clear selection
If yes, please explain.
Your answer
Has your cat been to the vet for routine care (annual checkups, vaccinations, etc.)
yes
no
Clear selection
If yes, do you have vet records that you could provide us?
yes
no
Clear selection
Is there anything else we should know about your cat's medical history?
Your answer
HOUSEHOLD HISTORY
How would you describe your cat's usual behavior? (check all that apply)
friendly to family
friendly to visitors
shy to family
shy to visitors
more like a dog
very active
playful
affectionate
quite
fearful
a clown
aloof
talkative
lap cat
fearless
couch potato
withdrawn
independent
solitary
Does your cat do any of the following? (check all that apply)
jump or counters
scratches doors/cabinets
digs in garbage
scratch furniture
chew personal items
vocalizes too much
chew plants
climb curtains
Other:
If yes, how did your attempt to correct the problem(s)?
Your answer
Where does your cat like to sleep?
on furniture
no preference
in his/her bed
under furniture
with a person
anywhere sunny/warm
Other:
How did your cat usually interact with the following in your home?
Cats
Dogs
Children
Unfamiliar adults
Your answer
When playing does your cat ever bite, scratch or exhibit behaviors you would consider rough?
yes
no
Clear selection
If yes, please explain
Your answer
Was your cat allowed outdoors?
yes
no
Clear selection
If yes, did you have him/her on a harness and or leach while outside?
yes
no
Clear selection
Are there any wonderful, special traits or habits that you would like his/her new family to know about?
Your answer
LITTER BOX HISTORY
challenges surrounding litter box usage is one of the many reasons cats are surrendered to humane societies. Please help us by giving detailed and accurate information as possible.
Does your cat have 24 access to a litter box in your home?
yes
no
Clear selection
If no, did you cat use the bathroom outdoors!
yes
no
Clear selection
Is your cat particular about litter
yes
no
Clear selection
If yes, what type/brand?
Your answer
Is the litter box uncovered or covered?
uncovered
covered
Clear selection
Where is the litter box kept?
Your answer
How often is the litter box scooped?
every day
every few days
weekly
Other:
Clear selection
If you have other cats, how many shared a litter box?
one
two or more
multiple cats shared one box
Clear selection
Does your cat have accidents in the home?
yes
no
Clear selection
If yes, please describe the accidents...
urinates outside the box
defecates outside the box
urinates on clothing/furniture
sprays on walls/furniture
Other:
If yes, when did it begin?
past week
past month
past year
ongoing
Other:
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If yes, please describe the measures taken to correct this problem.
Your answer
If yes, has your cat been to the veterinarian to rule out infection or any underlying health issues?
yes
no
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If yes, what was the outcome?
Your answer
Your Address
Your answer
City, State, Zip
Your answer
Home Phone
Your answer
Work Phone
Your answer
Email Address
Your answer
Thank you for taking the time to fill out this form. Please sign below.
By signing below, I certify that all information giving is accurate and truthful to the best of my knowledge.
I agree that the above information is correct. Please type your signature here.
Your answer
Today's Date
MM
/
DD
/
YYYY
Amount of Surrender Fee Paid: $
Your answer
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