DOG SURRENDER Step 1 of 9 11% Date(Required) MM slash DD slash YYYY Owner Name(Required) First Last Phone(Required)Address(Required) Street Address Address Line 2 City Postal Code Pet's NameMicrochipAnimal's Gender female male AgeBreedColourVeterinary Clinic MedicalAre the dog’s vaccinations up to date? Yes No Is the dog spayed/neutered? Yes No Does the dog have any medical conditions? Yes No If yes, explainIs the dog currently given any medication? Yes No If yes, what medication?Has the dog been diagnosed with and/or treated for any of the following? ear infection allergies heart murmur tumors epilepsy or seizures organ failure urinary track infection thyroid disease diabetes other HomeIf the dog has lived with other cats, how did they interact? slept near each other played together chased the cat groomed each other ignored each other rough with the cat fight with injuries fight without injuries If the dog has lived with dogs, how did they interact? slept near each other played together peacefully co-existed ignored each other fearful of other dog fight with injuries fight without injuries Has the dog regularly been around children? no 0-2 years 3-5 years 6-10 years 11-18 years How did the dog interact with children? dog avoided child child could pet dog played together dog growled at child dog jumped on child ignored each other HistoryAre you this dog’s first owner? Yes No How long have you owned?How did you obtain this pet? pet store newspaper/internet rescue group stray breeder family/friend shelter other If rescue group or shelter, which one?Has the dog ever been used for breeding? Yes No Unknown Is the dog indoor/outdoor outdoor only When outdoors the dog was Tied Loose In fenced back yard When left alone the dog was Kenneled Loose Segregated to one area of house Loose in yard Outdoor Kennel Tied in yard Is the dog kennel trained? Yes No If yes, how long/often does the dog spend in a kennel?Does the dog have separation anxiety or is the dog destructive? Yes No If yes, explain?Can the dog be off leash? (Does it have recall to return when called?) Yes No How does the dog do on leash during walks? Walks well with no pulling Pulls when they see people/dogs Pulls during most of the walk Reactive to other dogs(barks/aggressive) Does the dog have any bad or unusual habits?Is the dog afraid of anything? PersonalityHow would you describe the dog most of the time? friendly to family friendly to visitors shy to family shy to visitors quiet very active playful loud/barks a lot fearful a clown withdrawn affectionate couch potato independent How does the dog like to play? plays gently likes to chase likes to play tug of war likes to play in or around water likes to play with dogs likes to play rough likes to play fetch likes to learn tricks for treats not interested in play DietWhat brand of food is the dog currently eating?Type of food? canned dry both What treats does the dog enjoy?How often is the dog fed? food always available designated mealtimes House Training HabitsDoes the dog ever have accidents in the house? Yes No If yes please explain SurrenderWhat is the reason for surrender?(Required)Has the dog ever bitten a person?(Required) Yes No Unknown Did the bite break skin?(Required) Yes No Unknown If yes, Date of bite(Required)Was medical attention required?(Required) Yes No What was the circumstance leading up to the bite(s)?(Required) I hereby authorize that the following animal(s) are from Thunder Bay, Ontario District. I confirm that the animal is my legal property. By putting the animal into the Thunder Bay & District Humane Society’s shelter care, I am giving full custody to the shelter and therefore this cannot be reversed. By signing this, I am fully aware that I am surrendering my full legal rights to this animal. If found untruthful, I will be held liable to any fees accumulated and to an Animal Welfare investigation.Name of Animal(s)Date MM slash DD slash YYYY Signature of Owner(Required)Print Name First Last If not owner of record, please state relationship to ownerI also authorize the TBDHS to receive all veterinary records from any of the veterinarians I have used.Signature(Required)NameThis field is for validation purposes and should be left unchanged.