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2. 
3. Canine Surrender Questionnaire

   No one knows and loves your dog the way you do! In order to find the most appropriate home for your dog, please complete the following form.    

   Please note: Submitting this questionnaire online is NOT a confirmation of an appointment. To schedule an appointment to surrender an animal, please call the shelter during business hours at (859) 356-7400 to speak with a staff member.

8. Dog Name:*
9. Sex:*

   1. Male
   2. Female
11. Breed(s):*
12. Age:*
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14. Owner First Name:*
15. Owner Last Name*
17. Address*
19. City*
20. State*
21. Zip Code*
23. Phone Number*
24. Email Address
26. Relationship to dog:*

    1. Owner

    1. Caretaker

    1. Foster

    1. Finder (stray)
28. Reason for Surrender: *
30. How long have you had this pet?*
31. Where did you get this pet?*
33. Spayed/Neutered?*

    1. Yes
    2. No
    3. Unknown
34. Microchipped?*

    1. Yes
    2. No
    3. Unknown
35. Up-to-date on vaccinations?*

    1. Yes
    2. No
36. Do you have the paperwork?*

    1. Yes
    2. No
38. Veterinarian:
39. Last Visit:
    Last Visit:
41. Please list any past or present injuries, treatments, allergies, or other medical history:*
43. Is your dog currently on any medications?*

    1. Yes
    2. No
44. If yes, please list:*
46. Has your pet ever been involved in a bite incident?*

    A bite incident is qualified by any incident where an animals' tooth or teeth break skin on a human or other animal.

    1. To a human
    2. To another animal
    3. Neither
47. If yes, date the incident occurred: *
    If yes, date the incident occurred:
49. Describe the bite incident:*
51. Is the dog housebroken?*

    1. Yes
    2. No
    3. Partially
52. Is the dog crate trained?*

    1. Yes
    2. No
    3. Partially
53. Does the dog do well in the car?*

    1. Yes
    2. No
55. Has the dog lived with:*

    1. Cats
    2. Dogs
    3. Children
56. For children, what ages?*
58. Would you recommend your dog live with cats, dogs, or children in the future? Why or why not?*
60. Is the dog protective or may bite over any of the following with humans?*

    Check all that apply

    1. Food
    2. Treats, chews, etc.
    3. Toys
    4. Being woken up

    1. Being picked up
    2. Stranger in the home
    3. Being brushed or groomed
    4. Other
61. If other, please list:*
63. Is the dog protective or may bite over any of the following with other animals?

    Check all that apply

    1. Food
    2. Treats, chews, etc.
    3. Toys

    1. Being woken up
    2. Other
64. If other, please list:*
66. Where does the dog spend most of their time?*
68. How long is the dog left alone, without people, during the day?*
70. When left alone, does the dog ever show any of the following behaviors?*

    1. Destructive
    2. Urinate/defecate
    3. Bark
    4. Cry
    5. Other
71. If other, please explain:*
73. Is the dog an escape artist (climbing fences, escaping crates, etc.)?*

    1. Yes
    2. No
75. Does the dog know any commands?*
77. What are your dog’s favorite activities or objects?*
79. What does the dog dislike or fear?*
81. Check all of the following that describe your dog:*

    1. Very active
    2. Friendly
    3. Separation anxiety
    4. Couch potato
    5. Shy

    1. Barks a lot
    2. Quiet
    3. Playful
    4. Affectionate
    5. Fearful

    1. Independent
    2. Protective
    3. Digger
    4. Worked livestock
83. Any additional information that will help us place your dog in the best home for their needs?*
Leave This Blank:


85. 1. Receive an email copy of this form.
86. Email address

    This field is not part of the form submission.

87. Submit

* indicates a required field