1). Why do you want to surrender this animal?

2). Does this animal have any known health problems? On any medications?

3). Is the animal spayed/neutered?

4). How old is this animal?

5). When did this animal last receive vaccinations? What vaccines were given?
Cats: Distemper combo/Panleukopenia, FeLV, Rabies, deworming
Dogs: Distemper/parvo combo, Rabies, Lyme, Heartworm check and prevention, deworming

6). Does this animal have any behavior problems?

7). Has this animal ever bitten anyone? If yes, when.

8). Has this animal been around children or other pets? Any problems?

9). What have you been feeding this pet? Any special dietary requirements or allergies?

Other Comments:

Description of animal(s)/Case #___________________________________

SCHS Agent______________________________

Date______________________________________