Dog Surrender Form

To help us provide the best care possible, pet surrenders are accepted by appointment only. This allows our team to make sure we have the space, staff, and resources needed to properly support each animal coming into our care. Once we have processed the surrender form and there is space available, staff will call to schedule an appointment time.

We know that making the decision to surrender a pet can be incredibly emotional, and you don’t have to navigate it alone. Our team is here to talk through your situation, explore possible options, and see if there are ways to help keep your pet in your home. If surrender is the only option, we will work with you to schedule an appointment and guide you through the next steps with care and understanding.

ID #

(Please leave this field blank. ID# will be added once the form is submitted).

Date(Required)

MM slash DD slash YYYY

Owner's Name(Required)

First Last

Phone(Required)

Email(Required)

Owner's Address(Required)

Street Address Address Line 2 City Province Postal Code

Dog's name(Required)

Dog's gender(Required)

Dog's breed(Required)

Dog's colour(Required)

Dog's age(Required)

Is your dog spayed or neutered?

Yes

Don't Know

Is your dog microchipped or tattooed?(Required)

Microchipped

Tattooed

Neither

Please provide the microchip number, if available.

Why are you surrendering your dog?(Required)

How long has your dog lived with you?(Required)

Do you have current vaccine records for your dog?(Required)

Yes

When was the last time your dog was seen by a veterinarian?(Required)

Never

6 months

1-3 Years

3+ years

What is the name of your veterinary clinic?(Required)

Does your dog have any known health problems/old injuries?(Required)

Describe this dog at a vet exam:(Required)

No signs of fear or anxiety, purrs, easy for vet to handle

Some panting or whining, vet can still handle

Panting or whining plus salivating or trembling, difficult to handle

I have never taken this dog to a vet

Other

Has your dog ever worn a muzzle?(Required)

Yes

Please state what the circumstances were.

Where did you get your dog?(Required)

Sarnia & District Humane Society

Found/Stray

Breeder

Someone Rehoming

Another Humane Society/Rescue

Friend/Relative

Other

If you got this dog from someone rehoming them, why were they rehoming them?

How many hours per day is your dog normally left alone?(Required)

1-4 hours

4-8 hours

8+ hours

Other

Where is the dog kept when no one is home?(Required)

Crate

Basement

Confined Area

Free Run/Not Confined

Other

What does this dog do when left home alone? Check all that apply.(Required)

Rests

Barks

Chews things like garbage, remote, toilet paper, etc

Chews things like doorframes, baseboards, etc

Other

Does this dog require grooming?(Required)

Yes

If this dog requires grooming, who does it?

Owner

Groomer

N/A

Other

If this dog requires grooming, how does the dog react?

Stands calmly without signs of fear/anxiety

Tolerates it with some signs of fear/anxiety

Growls, bares teeth or snaps & requires a muzzle

N/A

Other

Who trims the dogs nails?(Required)

Owner

Groomer

Vet

Nobody/Never Been Done

Other

How does the dog react to their nails getting trimmed?(Required)

Sits calmly without fussing

Fusses a bit but still allows it

Fusses a lot and takes more than one person or more than one try

Requires sedation

I've never had their nails trimmed

Is there any body part that your dog does not like you to touch?(Required)

Head

Stomach

Tail

Paws

Legs

Other

Is your dog afraid of anything that you are aware of?(Required)

Fireworks

Vacuum Cleaner

Water

Cars

Traffic

Feet/Hands

Walking at Night

Thunderstorms

Other

What does this dog do if you try to take something away from them?(Required)

Nothing, let it be taken

Stiffen or hover over it

Growl or bare teeth

Snap or bite

I have never tried

Other

Where does your dog sleep?(Required)

Owner’s Room

Crate

Doghouse/Outside

Other

How many adults (18+) live at home?(Required)

How would you describe this dog with the adults in the home?(Required)

Always wants to be around the owners receiving affection

Will seek out attention sometimes but also spends a lot of time on own

Tends to shy away from owners when owners try to pet them

Tries to stop owner from petting them by growling, baring teeth or snapping

Other

How many children live in the home?(Required)

How old are the children in the home?

How would you describe this dog with the children in the home?(Required)

Seeks out children for attention, chooses to be around children

Doesn’t seek out children for attention, but doesn’t show fear or aggression when children try to pet

Cowers when children are nearby, chooses to leave area children are in

Growls, bares teeth or snaps when children try to pet

I have not seen this dog around children

Other

How does this dog interact with visitors?(Required)

Approaches visitors for petting and attention

May approach to sniff but then leaves visitors alone; doesn’t show fear or aggression

Barks or growls at visitors and backs away if they try to pet

Tries to bite if visitor pets

Other

Are there other pets in the home?(Required)

Dog(s)

Cat(s)

Small animal(s) (e.g. rabbit, rat, lizard, bird)

No other animals live in the home

Other

How does this dog interact with dogs in the home?(Required)

Play together and get along well

No aggression or fear between them but they don’t really interact

Avoids other dog and may show fear when other dog is around

Growls or bares teeth at other dog often

There are no other dogs in the home

Other

What does this dog do when seeing dogs on walks?(Required)

Ignores them/hardly notices them

Stops and stares at the other dog

Stares at the other dog and keeps walking

Pulls on leash/tries to get to the other dog

Low pitch barks (non-friendly) or lunges toward them

Whines or high pitch barks at the other dog

Other

Have you taken this dog to the dog park/places to play with other dogs?(Required)

Yes — This dog enjoys playing with other dogs

Yes — This dog tends to shy away from other dogs

Yes — This dog seems indifferent to other dogs and ignores them

Yes — This dog has shown aggression towards other dogs

No — This dog is not good with other dogs

No — For reasons not related to how this dog is with other dogs

How does this dog interact with cats indoors?(Required)

Sniffs cat with loose body language

Sniffs cat and may try to play gently

Ignores cat

Chases cat

Growls, bares teeth or snaps at cat

I have not seen this dog around a cat indoors

Other

How does this dog react when seeing a cat outside while on a walk?(Required)

Ignores them/Hardly notices them

Stops and stares at the cat

Whines or high pitch barks at the cat

I have not seen this dog around a cat outside while on a walk

Lunges or tries to chase the cat

Other

When does this dog bark?(Required)

When does this dog growl?(Required)

How much exercise does this dog get a week?(Required)

What do you walk this dog on?(Required)

Regular collar

Prong collar

Body Harness

Martingale collar

Choke chain

Head halter

Other

Has this dog ever worn a shock collar?(Required)

Yes

If so, how has the shock collar been used? Check all that apply.(Required)

Bark collar that shocks automatically when they bark

Electric fence collar that shocks if they go too close to the perimeter

Shock collar that the human controls for training

Other

If this dog has worn a shock collar for training purposes (where you control the shock), please elaborate on the training or contexts in which it has been used (e.g. when they react to a dog on walks).

Has this dog ever worn a prong collar?(Required)

Yes

If so, how has the prong collar been used? Check all that apply.

Leash correction when they do something unwanted

Used to stop pulling

Other

What things does this dog do that you wish they would stop?(Required)

What things have you done to try to get them to stop?(Required)

Has this dog been to a trainer?(Required)

If this dog has been to a trainer to address unwanted behaviours, what were the behaviours?

What instructions did the trainer give for the unwanted behaviours?

What type of food is this dog being fed?(Required)

Canned

Dry

Table Food

Other

Please provide the brand of food your dog is being fed. Also provide the type of food if you chose other last question(Required)

What toys does this dog enjoy? Check all that apply(Required)

Squeaky/stuffy toys

Tennis balls

Rope toys

Rubber toys

Tough nylon bones

Do they destroy toys?(Required)

Yes

How does this dog react during car rides? Check all that apply.(Required)

Lay down and relax

Calmly look out the window

Pants, trembles or salivates anxiously

Eagerly jumps in vehicle

Scared to enter vehicle

Other

How does this dog enjoy swimming?(Required)

Will jump into water happily on their own

Will go into water sometimes if others are swimming

Might go in with coaxing but gets out quickly

Avoids water

Unknown – I have never seen this dog around a body of water

Other

Has this dog bitten a person or animal? If so, how many times?(Required)

If this dog has bitten, has it even drawn blood?

Yes

If this dog has bitten, has it ever resulted in a trip to the hospital/doctor?

Yes

Please describe any bite incidents

Is there anything else we should know?(Required)

Please provide a picture of your pet

Accepted file types: jpg, gif, png, heic, Max. file size: 64 MB.

Was a photo provided?(Required)

Yes, a photo was provided

No, I could not provide a photo at this time

Is there anything else we should know about your dog?

The Sarnia & District Humane Society is dedicated to ensuring no healthy adoptable animal is euthanized, thereby increasing the live release rates of pets in its care. It is our mandate to exhaust all efforts before euthanasia is considered. Every animal’s life deserves a conversation. Euthanasia may be considered as a last resort for unhealthy and untreatable animals.

If this animal should not be considered an adoption candidate for behaviour or medical reasons, would you like to be informed prior to euthanasia?(Required)

Yes

Consent(Required)

I agree that I understand the question above.

Should you select "No" to being notified about euthanasia, in the previous question, you WILL NOT be contacted in the event that euthanasia has been decided.

By clicking the box below, you the owner, understand that you are relinquishing ownership of the cat; all decisions pertaining to the cat will now be made by The Sarnia & District Humane Society; the possibility that a decision may be made to euthanize and if that decision is made, you have the option to be notified. You also understand that if you selected “NO” to being notified about euthanasia, you will not be contacted, in the event that euthanasia has been decided.

Consent(Required)

I agree to the terms and conditions of this form

Date

MM slash DD slash YYYY

Note: The Sarnia & District Humane Society at no time will sell, lend or give your personal information to any group or person. This includes List Brokers, Mail Order Businesses, Telemarketers or other companies who would sell their services or products. All information is stored in a secure manner in accordance with the Personal Information Protection and Electronic Documents Act.