PROGRAMS & SERVICES / ANIMAL SURRENDER

Dog Surrender Form

Tell us about your dog so we can understand their needs and help support their next chapter.

Pet owner with animal and compassionate support

Before a Surrender Can Be Considered

You must have the knowledge and consent of all members of the household, be 18 years of age, have valid I.D. and a current address, and understand that the Northumberland Humane Society has the right to refuse your application.

Tell Us About Your Dog

Before you send this form

Why we ask for a donation. The Northumberland Humane Society is a charitable community resource. In lieu of a surrender fee, we kindly ask for a donation. Your donation helps support providing food and general care; veterinary care; spaying/neutering; vaccinations, microchipping and deworming treatment; and maintenance of the shelter.

Release of medical information and veterinary records. I hereby request that the veterinarian named in this form release any information pertaining to the animal(s) named in this form contained in the veterinary records at the clinic named in this form to the Northumberland Humane Society. This request and authorization is limited to the above-noted agency. This shall be your good and sufficient authority for doing so.

Dog's name *

Owner Information

Name *

Phone number(s) *

Address *

Apt #

City *

Postal Code *

Email *

General Information

Gender Male Female Unknown

Spayed / Neutered Yes No Unknown

Age

Breed

Colour

Identification details

Identification Tattoo Microchip None / Unknown

Recent photo of your dog (optional)

JPG, PNG or WebP, up to 2 MB. Large photos are shrunk for you before they are sent.

History

Why are you surrendering this dog? *

If we could help you resolve this issue, would you be interested in keeping the dog?

How long have you owned this dog?

Where did you acquire this dog?

Has your dog ever bitten anyone before? If yes, under what circumstances and when?

If yes, is the incident documented with By-law, Animal Control or Public Health?

Medical

What veterinary clinic does the dog visit?

Has this dog seen a veterinarian at least once per year? Yes No Unknown

Is this dog currently up to date with vaccines? Yes No Unknown

Date of last vaccination

Has this dog ever required medical surgery? Yes No Unknown

If yes, please explain (surgery)

Has this dog ever been diagnosed and/or treated for any medical problems? Yes No Unknown

If yes, please explain (medical problems)

Is your dog currently receiving any medication?

Have you noticed any coughing with your dog in the past week? Yes No

In the last 7 days, where has your dog been in close contact with other dogs (e.g. rescue, boarding, groomer, daycare, dog park, pet supply store, vet clinic)?

Dietary Habits

Is your dog on a prescription diet? Yes No

What brand of food are you currently feeding your dog?

Which does your dog eat? Dry only Can only Combination of both People food

How often is your dog fed? Once a day Twice a day Free fed

Training

Is your dog housetrained? If not, how often does the dog have accidents?

Has your dog received obedience training? If yes, from whom and what methods were used?

What are the basic commands your dog knows? Sit Stay Down Come Heel Drop It Other

What walking equipment works best with your dog (e.g. flat collar, head halter, front-clip control harness, pressure collar, limited slip collar, prong collar, choke chain, electric collar)?

How is your dog's behaviour off leash?

Is your dog used to being in a fenced yard? Yes No Unknown

Will your dog chew household items when left alone? Yes No Unknown

Does this dog bark: Rarely/Seldom Alarm only Frequently At anything

Please elaborate (barking)

Has this dog been crate trained? Yes No Unknown

Personality

How would you describe your dog's personality most of the time? Very Active Playful Affectionate Friendly to Visitors Couch Potato Lap Dog Distant Shy to Visitors Talkative Quiet Fearful Independent Aggressive Other

Play Style

How does your dog like to play?

Lifestyle & Home Life

If this dog has lived with other cats, how did they interact?

Does this dog get along with other dogs?

If this dog has lived with dogs, how did they interact?

Has the dog regularly been around children? Yes No Unknown

If yes, indicate what ages

How did the dog and the child interact?

Have experiences with the dog and child(ren) always been positive? Yes No

If no, please explain (children)

Is the dog most comfortable with: Women Men Kids Teenagers Seniors Loves all people

Please tell us some things your dog dislikes

Please tell us some things you truly love about this dog!

Are there any quirks or habits you are not fond of in your dog? This information helps shelter staff understand your pet and can help support a successful future adoption

Additional Information

Is there anything else that you would like us to know about your dog?

Release of Medical Information and Veterinary Records

Veterinarian's name *

I authorize the veterinarian named above to release this animal's veterinary records to NHS (this authorization is limited to NHS) *

Your full name (typed as your signature) *

Sorry, we could not send your form. Please try again, or call us at 905-885-4131.

Thank you

We've received your surrender form. A member of the NHS team will review it and be in touch. If your situation is urgent, please call us at 905-885-4131.

JavaScript is off, so sending this form lands on a plain confirmation page. You're welcome to send it anyway, or call 905-885-4131 or email info@northumberlandhs.com instead.