Cubaka - Gulf Coast Humane Society

PET INTAKE FORM

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Date(Required)

Pet’s Name(Required)

Pet Type(Required)

Dog

Cat

Pocket Pe

Breed(Required)

Approximate Weight:(Required)

Color(Required)

Age / D.O.B(Required)

Sex(Required)

Fixed(Required)

Microchip(Required)

Up to date on vaccines?(Required)

Yes

(Attach vaccine records)

File

Max. file size: 50 MB.

Vet Name:

Vet Phone Number:

Why are you surrendering your pet?(Required)

Where did you acquire your pet?(Required)

How long have you had your pet?(Required)

Is your animal current on Heart-worm/Flea Prevention? If so, list below and attach medical records(Required)

Yes

Other

When last given

File

Max. file size: 50 MB.

Does your pet have any current or past health conditions or injuries? If so-list below and attach medical records(Required)

File

Max. file size: 50 MB.

Who does your pet get along with?(Required)

MEN

WOMEN

CHILDREN (1-3 years)

CHILDREN (4-7 years)

CHILDREN (8-11 + years)

DOGS

CATS

Has your pet ever shown signs of aggression?(Required)

Yes

If yes, was it provoked? Please explain

Does your pet live Indoors, Outdoors or both(Required)

What type of food does your pet eat?(Required)

Any destructive habits?(Required)

Yes

If yes, explain

Is your pet house broken / Litter trained?(Required)

Yes

Obedience training?(Required)

Yes

Please tell us about your pet and any special characteristic personality traits, or special needs:(Required)

STATEMENT OF SURRENDER

I certify that I(Required)

Do own the animal described above

Do NOT own the animal described above

I hereby surrender all interest to the Gulf Coast Humane Society. My interest in this animal has now been voided and I will not be given any information on the welfare or disposition of this animal.(Required)

Please type initials above

There is no minimum set time for holding this animal. The holding time depends on the animal’s health, behavior and adoptability. It is also agreed that neither said society nor its management and employees shall incur any obligation to me on the disposition of the above listed animal. I certify that this animal has not bitten another animal or human within the last 10 days. I have read and understand that I have surrendered my rights and interest towards this animal.

Signature(Required)

Date(Required)

The cost to care for and re-home pets can be in the hundreds of dollars for each animal that comes into our care. GCHS is a private, non-profit organization that does not receive government funding. We are also not affiliated with any national humane organizations. GCHS asks for a surrender fee to help subsidize this cost. The fee is non-refundable and will be collected only if we are able to accept your animal after its evaluation and required testing. Dogs - $100.00 if not spayed/neutered Dogs - $75.00 if spayed/neutered Cats - $50.00

Signature

Date

Name

This field is for validation purposes and should be left unchanged.

Gulf Coast Humane Society

About Us

Adopt

Way To Give

Our Clinics

Pet Resources

Volunteer / Events

About Us

Adopt

Way To Give

Our Clinics

Pet Resources

Volunteer / Events

PET INTAKE FORM

STATEMENT OF SURRENDER