First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County

Email*

Home Phone*

Cell Phone*

Alt Email

Text/Pager Email

Name of Animal*

Microchip #*

Dog's Gender

Have they been spayed or neutered?*
Choose one: Yes No N/A

Breed*

Are you 18 years of age or older?*
Choose one: Yes No

Please select one*
Choose one: Puppy Adult Senior

How old is the dog?*

How much does the dog weigh?*

Why are you surrendering this pet for adoption?*

Is this dog a stray?

Has the dog been seen by a vet?

If yes, the name of the vet and date last seen.*

Please list vet address and phone number

Do you have medical records for the dog? If yes, please email a copy to animaladvocatesfl@gmail.com

Are there any illnesses, accidents or chronic problems? If so, please list any conditions.

What type of flea prevention do you use?

What type of heart worm prevention do you use?

In order to place your/this pet in a home that best fits their needs, we need some additional information about them. Please be as honest as possible. Many problem issues can be addressed with training if we know about them. Check all that apply:

I am the owner/party that found this animal and hereby relinquish all present and future rights and claims to this animal and his/her possessions transferred with him/her to Animal Advocates, FL. I certify that I have fully informed the individuals/organization above of all known or suspected problems and concerns about this animal. Further, I have indicated all information possible to ensure the animal has continued happiness and welfare. I understand that I may not be provided with information about this animal’s whereabouts. To the best of my knowledge, this animal has no defects or problems that would make it unsuitable as a family pet.*

Please check box as indicated