test dog page - The Humane Society of Memphis & Shelby County

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Owner Surrender Information

Your Name(Required)

First Last

Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Dog Surrender Information

Dog's Name(Required)

Breed(Required)

Color(Required)

Sex(Required)

Spayed/Neutered?(Required)

Age(Required)

Weight(Required)

Who is your vet?(Required)

Is your dog up to date on his/her vaccinations?(Required)

Date of rabies(Required)

Tag #(Required)

Where did you get the dog?(Required)

How old was he/she when you got her/him?(Required)

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

What Brand and flavor of food does your pet currently eat?(Required)

Why are you surrendering the dog to us? Please be as descriptive as possible.(Required)

Check all that apply to describe your dog’s personality(Required)

Friendly

Shy

Independent

Fearful

Playful

Affectionate

Aloof

Aggressive

Overly Reactive

What is your dog afraid of?(Required)

Where is your dog sensitive about being handled? (example – ears, feet, etc.)(Required)

When does your dog become irritated?(Required)

Where does your dog spend most of the time?(Required)

Inside

Outside

Inside/Outside

Do you have a fenced yard?(Required)

Yes

If not, do you have a tie-out or runner for your dog?(Required)

Did you have an electric fence?(Required)

How long is your dog left in the yard each day?(Required)

Do you take your dog for leash walks?(Required)

How often?(Required)

How does he/she walk on the leash?(Required)

How long is your dog left alone inside your home each day?(Required)

Is she/he free or confined?(Required)

If confined, where/how?(Required)

Is the dog crate trained(Required)

Yes

Unkown

Do you still use the crate?(Required)

Does your dog have accidents in the house?(Required)

Yes

Unknown

If yes, how often?(Required)

Does the dog destroy things in the house or yard?(Required)

Yes

Unknown

What items?(Required)

How often?(Required)

If your dog does destroy things or has accidents, is it only when he/she is left alone?(Required)

Does your dog:

Run away

Bark too much

Jump up on people

Dig in the yard

Other

What does your dog do when:

The mailman or UPS man comes to your home?(Required)

A stranger/visitor knocks on the door?(Required)

A stranger/visitor comes into the house(Required)

A visitor tries to pet him/her inside your home?(Required)

A stranger approaches you while on a walk?(Required)

A stranger attempts to pet him/her while on leash with you?(Required)

Unfamiliar people walk by the home when he/she is in the yard?(Required)

You or someone else goes near the food bowl when he/she is eating(Required)

You or someone else tries to take away toys, rawhide, or anything else of value?(Required)

You or someone else tells him/her to get off the sofa or bed(Required)

You or someone else gives him/her a hug?(Required)

You or someone else bathes or grooms him/her(Required)

You or someone else reprimands him/her?(Required)

Has your dog ever lived with children?

Yes

Unknown

If yes, what ages?(Required)

Is your dog good with those children (friendly, tolerant)?(Required)

If no, please explain.

If your dog doesn’t live with children, how often does he/she interact with children?(Required)

What does your dog do if:

A child is crying /screaming?(Required)

A child runs towards him/her?(Required)

He/she sees a child on a bike?(Required)

He/she sees a child running?(Required)

You pick up a child?(Required)

When was the last time your dog snarled at you or someone else? (please explain situation(Required)

When was the last time your dog growled at you or someone else (please explain situation)(Required)

When was the last time your dog snapped at your or someone else? (please explain situation(Required)

When was the last time your dog nipped you or someone else? (please explain situation)(Required)

When was the last time your dog bit and broke skin on you or someone else (please explain situation)(Required)

What other animals has your dog lived with?(Required)

Did he/she do well with the house cat/s? Any issues?(Required)

Did she/he get along with other dogs? Any issues?(Required)

How does your dog react when he/she sees an outdoor cat?(Required)

How does your dog react when he/she sees another dog outside?(Required)

Is her/his behavior different when on leash compared to when off leash at seeing another dog?(Required)

Has your dog ever fought with another dog?(Required)

Has your dog ever injured another dog?(Required)

Have you ever taken your dog to a training class?(Required)

or have you trained him/her yourself?(Required)

What kind of training have you tried?

Choke chain

Electric shock

Treats

Praise

Clicker

What behaviors does he/she know?

Sit

Down

Stay

Come

Shake

Roll over

Other

How do they ride in a car?(Required)

What behaviors do you wish he/she knew?(Required)

What is your dog’s favorite game or toy?(Required)

What is your dog’s best quality?(Required)

What is your dog’s worse quality?(Required)

Please include any additional comments you would like to share about this dog.(Required)

Thank you for answering these questions honestly. Everything you have told us about your dog is important to help us in finding him/her an appropriate home.

I understand that this form is the first step in the intake process, and the intake of this animal is not guaranteed by HSMSC.

Signature

Dog Surrender Form

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Owner Surrender Information

Dog Surrender Information

What does your dog do when:

What does your dog do if:

Thank you for answering these questions honestly. Everything you have told us about your dog is important to help us in finding him/her an appropriate home.