Meriden Humane Society Canine (Dog) Request to Surrender Form
Meriden Humane Society Canine (Dog) Request to Surrender Form
Please fill out this form to add your canine to our evaluation and intake waiting list.
Owner Information
First Name
*
Last Name
*
Street Address
*
City
*
State
*
Zip Code
*
Cell Phone
*
Home Phone
Email Address
*
Canine Information
Canine Name
*
Gender
*
Male
Female
Species
*
Dog
Cat
Breed
*
Canine Age? Ex. 1yr 4mo
*
Canine Size
*
Very Large
Large
Medium
Small
Is your canine microchipped?
*
No
Yes
Is your canine spayed or neutered?
*
No
Yes
Up to date on shots:
Up to date on Rabies?
*
No
Yes
Up to date on Distemper?
*
No
Yes
Up to date on Bordetella?
*
No
Yes
Vet Information (Name and Phone#)
Are you able to provide vet records to support vetting history? (Please Note: In order to expedite the surrender process, please contact your vet and give them permission to provide vetting information on the animal in question)
*
No
Yes
How long have you had your canine? Ex. 3yr 3mo
*
Did you adopt your dog from an Organization?
*
No
Yes
Did you adopt your dog from the Meriden Humane Society?
*
No
Yes
If not MHS, please include Organizations Name and State
*
Does your canine have any medical issues?
*
No
Yes
If yes, what is his/her condition(s)?
Behavioral Issues
Food Aggression?
*
Yes
No
Unknown
Other Canine Aggression?
*
Yes
No
Unknown
Feline Aggression?
*
Yes
No
Unknown
Good with children?
*
Yes
No
Unknown
Toy Aggression?
*
Yes
No
Unknown
Other types of aggressions noted?
Why are you choosing to surrender your canine?
*
What is the best way to contact you?
*
Email
Cell Phone
Home Phone
Please Note: Filling out this form does not guarantee you an evaluation appointment. As of 12/1/2018: MHS requests a $100 canine surrender donation.
