Your Name (first and last) (required)
Your Phone Number (required)
Your Email Address (required)
Your full address (required)
Today's Date (required)
Why are you surrendering the pet? Give as much detail as possible. (required)
Cat's Name (required)
Nickname (required)
Age or Approximate Age (required)
How long have you had the cat at your home, inside or outside? (required)
If a stray cat how long has it been in the neighborhood?
Breed of cat (required) —Please choose an option—DSHDMHDLHSiameseOther/Unknown
If another breed or unknown, please describe:
Is the cat (required) —Please choose an option—MaleFemaleUnsure
Has the cat been spayed or neutered? (required) —Please choose an option—YesNoUnsure
Does the cat have a microchip? (required) —Please choose an option—YesNoUnsure
Is the cat declawed? (required) —Please choose an option—NoYes-front declawedYes-all four declawed
Where did you acquire the cat? (required) —Please choose an option—CCHSShelter or RescueFound as strayFriend/RelativePet StoreBreederNewspaper/Internet AdBorn in home/on propertyOther (enter below)
Other
If you have obtained this animal from another shelter, breeder, rescue group, or pet store, please provide the name and location of the source
Describe in your own words the personality of your cat (required)
Which of the following does your cat eat? Check all that apply (required) Dry food onlyCanned food onlyCombination of dry and canned foodTable ScrapsHome cooked dietGrain free diet
What brand of cat food and treats? (required)
Special diet and why?
Have you taken this cat to the veterinarian? (required) —Please choose an option—YesNo
If yes, Name of veterinarian?
If yes, Date of last visit?
Is cat current on his/her vaccines (Rabies, Distemper Combo)? (required) —Please choose an option—YesNoUnsure
Does the cat have any medical issues? (required) —Please choose an option—YesNoUnsure
If yes, please explain
Is the cat on any medications? (required) —Please choose an option—YesNo
If yes, please list medications
Please check all conditions that your cat has been diagnosed with or has been treated for (required) AllergiesUrinary Tract InfectionEpilepsy/SeizureDiabetesThyroid DiseaseSkin ProblemsRingwormHeart MurmurHeartwormOrgan FailureOtherNone of the above
How does the cat behave at the vet's office? (Check all that apply) (required) Calm/RelaxedAnxiousFearful/IndefferentAggressiveUnsure
Traits that best describe your cat's personality (check all that apply) (required) EnergeticShy/reservedTalkativePlayfulLap catFriendlyIndependentFearfulAvoidantAggressive
Other personality traits:
What is your cat's favorite style of play? (check all that apply) (required) GentleEnergeticEnjoys PlayingDoes not show much interest in playingLoves toysWill learn tricks for treatsLikes to chase wand toysLikes catnipLikes to chase mice/ballsLikes to chase laser pointer toy
Other forms of play your cat enjoys:
How is your cat about getting into a carrier? (required)
How is your cat about riding in a car in a cat carrier? (required)
Does your cat respond to calming techniques (calming sprays, cat nip, or special treats?)(required) —Please choose an option—YesNo
What makes your cat happy? (required)
Was the cat: (required) —Please choose an option—Indoors OnlyOutdoors OnlyIndoor/Outdoor
Where did your cat spend most of his/her time? (required) Living roomKitchenBedroomAt the WindowBathroomBasementGaragePorchOutdoors
Does the cat have a favorite resting place? (check all that apply) (required) BlanketBedCouchChairCat TreeWindowHiding SpaceCat BedOther
If other, please explain:
Did the cat have a favorite cat bed or blanket? (Required) —Please choose an option—YesNo
Were there other animals in the home? (Required) —Please choose an option—YesNo
If yes, please list the other animals in the home:
Describe how this cat behaved around other cats: (required) Avoided each otherPlayfulGroomed each otherSlept near each otherCaused each other stressFought with other catsPlayed roughPicked on other catOtherUnsure
Other:
Describe how this cat behaved around dogs: (required) Avoided each otherCat feared the dogPlayed too roughDog chased the catPeacefully coexistedDog stressed catCat tormented DogFought oftenPlayed nicely with each other
Has cat been around children - please select all ages that apply (required) No0-2 years old3-5 years old6-10 years old11-18 years old
How does this cat behave around children? (check all that apply) FriendlyPlayfulCalmAvoidantIndifferentFearfulAggressive
How does this cat behave around men? (check all that apply) FriendlyPlayfulCalmAvoidantIndifferentFearfulAggressive
How does this cat behave around women? (check all that apply) FriendlyPlayfulCalmAvoidantIndifferentFearfulAggressive
Did your cat have access to a litter box in the house? (required) —Please choose an option—YesNo
How many? (required)
If there were other cats, how many shared a litter box? —Please choose an option—12345+
If yes, did your cat use the litter box? (required) —Please choose an option—YesNo
What brand of litter was used? (required)
What kind of litter box did you use? (required)
What type of litter was used? (required) ScentedUnscentedClumpingNon-clumpingClayCrystal
What size litter box did you use? (required)
Was your litter box covered? (required) —Please choose an option—YesNo
How often do you scoop the litter box? (required) —Please choose an option—DailyEvery few daysWeekly
When was the most recent litter box accident? (required) —Please choose an option—Within a weekWithin a month1-6 months agoNever
Please describe the accidents:
If the cat urinates or defecates outside the litter box, does the cat most often go right beside the box? (required) —Please choose an option—YesNo
If not right by the litter box, where?
If litter box issues were a problem, when did they begin? —Please choose an option—Within the past monthWithin the past yearHas been an ongoing issue
Has your cat been examined by a veterinarian for his/her litter box issues to rule out medical problems contributing to the cat not using the litter box? (required) —Please choose an option—YesNo
If yes, what was the diagnosis/outcome?
Can you pinpoint an event that may have influenced/triggered poor litter box habits? What measures have you taken to correct the problem?
Tell us any unique characteristics/behaviors about your cat or any other comments about this cat you wish to add. Every bit of information you give us helps us in finding his/her a new family.
Send
