Owner Surrender Screening Form **INTERNAL USE ONLY** Owner Surrender Screening Form (INTERNAL USE) Date(Required) MM slash DD slash YYYY Which member of staff is filling out this form?(Required) Urgency of Surrender(Required) Routine Urgent Name of Owner/Guardian(Required) First Last Phone(Required)Email(Required) Address(Required) Street Address City State / Province / Region ZIP / Postal Code Reason(s) for Surrender(Required)Does the animal have any medical conditions?(Required)YesNoIf yes, please describe. Does the animal have any behavioural problems?(Required)YesNoIf yes, please describe. Does this animal have a bite history?(Required)YesNoIf yes, please describe the bite. A/H? Date of last bite?Animal Information: What is the animal's name?(Required) What species is the animal?(Required) What breed is the animal?(Required) How much does the animal weigh?(Required) How old is the animal?(Required) How long has the owner/guardian owned the animal?(Required) Where did the owner/guardian acquire the animal?(Required) Is the animal spayed/neutered?(Required)YesNoThe animal is...(Required)MaleFemaleAnimal #2: What is the animals name? What species is the animal? What breed is the animal? How much does the animal weigh? How old is the animal? How long has the owner/guardian owned the animal? Where did the owner/guardian acquire the animal? Is the animal spayed/neutered?YesNoThe animal is...MaleFemaleFax Vet Records Yes What vet clinic has this animal been seen at?(Required) The Owner Surrender Form has been sent? Yes Surrender appointment has been booked? Yes If yes, the appointment is booked for the following date: I have instructed the owner/guardian to bring toys, food, leash, bed, etc. upon drop off.(Required) Yes Notes for StaffFast-track animals without medical or behavioural problems providing space is available. Any animals with red flags is considered urgent. Refer request to Adoption/Intake Coordinator or the Animal Care Manager.
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