General Information:
*
Name:
*
Email: Required
*
Street 1: Required
Street 2:
*
City/State/ZIP:
*
Phone Number: Required
*
Gender: Required
Male
Female
Other
Required
*
Date of Birth: Required
Date of Birth:
Month
Jan
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Remember me. What's this?
An appointment is requested so we're better prepared for your animal's arrival. To schedule a surrender appointment, please complete this form and call the campus nearest you:
Milwaukee Campus: 414-431-6102
Racine Campus: 262-554-6699
Ozaukee Campus: 262-377-7580
Green Bay Campus: 920-469-3111
Door County Campus: 920-746-1111
*
Question - Required -
Do you have a surrender appointment scheduled at one of our campuses?
Please select response
Yes
No
*
Question - Required -
If "yes" to the above question, at which campus did you schedule the appointment?
Please select response
Milwaukee Campus
Ozaukee Campus
Racine Campus
Green Bay Campus
Door County Campus
No Appointment Scheduled
*
Question - Required -
Cat's Name:
*
Question - Required -
Breed or Markings:
*
Question - Required -
Color:
Question - Not Required -
Age:
*
Question - Required -
Sex:
Please select response
Male
Female
*
Question - Required -
Spayed or Neutered:
Please select response
Unknown
Yes
No
Question - Not Required -
Declawed:
Please select response
Not Declawed
Front Paws Only
All Four Paws
Question - Not Required -
If declawed, at what age?
*
Question - Required -
Where did you get your cat?
Please select response
Breeder
Pet Shop
Humane Society
Friend
Other
Question - Not Required -
If other, please specify:
*
Question - Required -
Why are you surrendering your cat to the Humane Society? (Be specific)
(Maximum response 255 chars, approx. 5 rows of text)
Question - Not Required -
How long have you owned your cat?
Question - Not Required -
What are two things you like the most about your cat's behavior?
(Maximum response 255 chars, approx. 5 rows of text)
Question - Not Required -
Have there been recent changes in the home? Example: moving, new pet, new baby
(Maximum response 255 chars, approx. 5 rows of text)
*
Question - Required -
Has your cat ever bitten anyone?
Please select response
Yes
No
*
Question - Required -
Did the bite break the skin?
Please select response
Yes
No
Question - Not Required -
How many times has your cat bitten?
Question - Not Required -
Explain the circumstances:
(Maximum response 255 chars, approx. 5 rows of text)
Question - Not Required -
Does your cat use his or her litterbox?
Please select response
Always
Sometimes
Never
Question - Not Required -
Does your cat:
Please select response
Poop outside the box
Pee outside the box
Pee and poop outside the box
Question - Not Required -
If sometimes, how often does your cat make mistakes?
Question - Not Required -
What surfaces and places does your cat choose to use instead of the litterbox?
(Maximum response 255 chars, approx. 5 rows of text)
Question - Not Required -
How many litterboxes can your cat access?
Question - Not Required -
How often is the litterbox(es) scooped out?
Question - Not Required -
How often are the litterboxes completely emptied and washed?
Question - Not Required -
What kind of litterbox does your cat use?
Please select response
Open
Hooded
Other
Question - Not Required -
If other, please describe:
Question - Not Required -
What kind of litter do you provide for your cat?
Please select response
Sand-like clumping litter
Clay
Other
Question - Not Required -
If other, please describe:
Question - Not Required -
Is the litter:
Please select response
Scented
Unscented
Don't know
Question - Not Required -
Where are the litterboxes located? (If you live in a multi-level home or apartment please indicate on which floor the boxes were kept, as well as location.)
(Maximum response 255 chars, approx. 5 rows of text)
Does your cat:
Question - Not Required -
Scratch furniture:
Please select response
Yes
No
Question - Not Required -
Chew plants:
Please select response
Yes
No
Question - Not Required -
Scratch on doors or cabinets
Please select response
Yes
No
Question - Not Required -
Chew personal items (clothing, shoes, etc.)
Please select response
Yes
No
Question - Not Required -
Does your cat use a scratching post?
Please select response
Yes
No
Question - Not Required -
What type of post does he/she use?
Question - Not Required -
How affectionate is your cat?
Please select response
1 - Not at all
2
3
4 - Somewhat
5
6
7 - Very
Question - Not Required -
Does your cat like to be picked up?
Please select response
1 - Not at all
2
3
4 - Somewhat
5
6
7 - Very
Question - Not Required -
Does he/she struggle to get down when picked up?
Please select response
Yes
No
Question - Not Required -
When you sit down does your cat jump onto your lap?
Please select response
1 - Never
2
3
4 - Somewhat
5
6
7 - Very
Question - Not Required -
Does your cat tell you to stop petting him/her?
Please select response
Yes
No
Question - Not Required -
If yes, how does he/she tell you to stop?
(Maximum response 255 chars, approx. 5 rows of text)
Question - Not Required -
Does your cat prefer to play:
Please select response
Roughly
Gently
Unknown
Question - Not Required -
What is his/hers favorite toy(s)?
Question - Not Required -
When playing does your cat nibble on hands?
Please select response
1 - Never
2
3
4 - Somewhat
5
6
7 - Very
Question - Not Required -
Does your cat ever play by pouncing on your feet?
Please select response
1 - Never
2
3
4 - Somewhat
5
6
7 - Very
Question - Not Required -
Does your cat live with other cats?
Please select response
Yes
No
Question - Not Required -
If yes, how many, what age and what sex?
Does your cat:
Question - Not Required -
Spend time and/or play with the cat(s):
Please select response
Yes
No
Question - Not Required -
Avoid the cat(s):
Please select response
Yes
No
Question - Not Required -
Actively fight with the cat(s):
Please select response
Yes
No
Question - Not Required -
Does your cat live with dogs?
Please select response
Yes
No
Question - Not Required -
If yes, how many?
Does your cat:
Question - Not Required -
Spend time and/or play with the dog(s):
Please select response
Yes
No
Question - Not Required -
Avoid the dog(s):
Please select response
Yes
No
Question - Not Required -
Actively fight with the dog(s):
Please select response
Yes
No
Question - Not Required -
Number of children in the home:
Question - Not Required -
Ages:
Does your cat:
Question - Not Required -
Spend time and/or play with children:
Please select response
Yes
No
Question - Not Required -
Avoid children:
Please select response
Yes
No
Question - Not Required -
Hide from children:
Please select response
Yes
No
Question - Not Required -
When guests come over does your cat:
Please select response
Solicit petting and attention from guests
Run and hide from guests
Run and hide but come out later to meet guests
Question - Not Required -
How comfortable is your cat with brushing:
Please select response
1 - Not at all
2
3
4 - Somewhat
5
6
7 - Very
Unknown
Question - Not Required -
How comfortable is your cat with clipping nails?
Please select response
1 - Not at all
2
3
4 - Somewhat
5
6
7 - Very
Unknown
Question - Not Required -
Does your cat have any medical problems or require medication?
Please select response
Yes
No
Don't Know
Question - Not Required -
If yes, please explain:
(Maximum response 255 chars, approx. 5 rows of text)
Question - Not Required -
Is your cat current on all vaccinations?
Please select response
Yes
No
Question - Not Required -
Has your cat been tested for Feline Leukemia?
Please select response
Yes
No
Question - Not Required -
How does your cat react when being seen by a veterinarian?
(Maximum response 255 chars, approx. 5 rows of text)
Question - Not Required -
What, if any, behavioral problems does the cat have?
(Maximum response 255 chars, approx. 5 rows of text)