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Pet Surrender Form

Date

Month

Day

Year

Name*

Phone*

Email*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

If caretaker is different from owner:

Caretakers name

Caretakers relationship to owner

Caretakers address

Caretakers phone

Caretakers email

Do you have the authority to surrender/ foster pet? Explain*

Owner admitted to/ or

Hospice

Nursing Home

Memory Care

Assisted Living

Rehab

Deceased

Other

Pet name*

Age/ Date of Birth*

Pet Breed*

Pets Weight (Approx)*

Is the pet current on all vaccinations?

Yes

No

Markings

Is your pet micro chipped?*

No

Yes

Did you get your pet from a rescue or shelter?*

No

Yes

Does this rescue/shelter have claim to this pet?

No

Yes

Is/does this pet:*

Completely housebroken

Paper-trained

Crate/ Litter trained

Have accidents

Where did the pet sleep at night*

Kept during the day*

How does the pet behave when alone*

Was the pet confined to your property*

Fenced area

Cable/ chain

Not confined

Does the pet jump fences*

No

Yes

Pets favorite activity*

Has the pet lived with other

Dogs

Cats

Birds

Children

Other

How did this pet get along with family members/ children*

Anything else you'd like to tell us

Signature*

Sign in the box or use the keyboard to type.

Signature field is empty.

Companion Animal Care (CAC) of Brevard County, FL ministers to those living on the Space Coast.

We are an approved I.R.S. 501(c)3 tax exempt nonprofit.

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