Lawrence County Humane Society
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Owner Surrender Form for Dogs
Please answer all questions honestly and completely. This is for your dog’s benefit as well as ours. We want to find the best match possible for your dog. Being dishonest or omitting information only hurts your dog.
Are you the owner?
Yes
No
Owner Info
Name
*
First
Last
Email Address
*
Phone Number
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Are you a resident of Lawrence County, PA?
Yes
No
Where did you acquire the dog from?
*
Why are you wanting to surrender the dog?
Dog Info
Name
*
Age
Breed
Color
Male/Female
Male
Female
Spayed/Neutered
Yes
No
Size
Small
Medium
Large
Is the dog indoor or outdoor?
Indoor
Outdoor
Does the dog have any health issues or allergies?
Yes
No
If yes, please describe
Does the dog require medications, special diet, and/or frequent vet visits?
Yes
No
If yes, please describe
Temperament
Has the dog ever bitten anyone?
Yes
No
If yes, please explain what caused the bite and the severity
*
Does the dog live and/or have lived with the following:
Other dogs
Cats
Children
Farm animals
Other small animals
If yes, how did they do with them?
Fears
Please check any of the following that your dog has issues with or fear of:
Bath
Nail trim
Car rides
Men
Fireworks
Storms
Strangers
Vet visits
Leash walking
Other
Please explain the behavior with the fear:
Does your dog have any behavioral issues with:
Food aggression
Resource guarding
Separation anxiety
Are they destructive?
*
Yes
No
Veterinarian's Name
*
Veterinarian's Phone Number
*
By signing below, I agree that the above information is true to the best of my knowledge:
Signature
*
Date
*
MM slash DD slash YYYY
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