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Date:
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Your Name:
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Street Address:
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Apartment No.:
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City, State, Zip Code:
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Telephone:
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(Home)
(Work)
(Cell)
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Email Address:
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Please enter your email address.
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Please enter a valid email address.
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Confirm Email Address:
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The email addresses must match.
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Where did you get the cat?
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How long have you had him/her?
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Why do you want to surrender your cat?
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How long can you keep the cat?
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If stray, where was the cat found?
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Cat Name:
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Breed:
Age:
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Gender:
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Please select the cat's gender.
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Fur Length:
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Please check the fur length of the cat.
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Coat color/markings:
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Eye color:
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Declawed:
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Please check if cat is declawed or not.
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Spayed/Neutered:
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If unaltered female,give date of last heat:
Please check if cat is altered or not.
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Is cat good with?
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If yes, ages:
Please check the ages of the children.
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Has the cat snapped, bitten, or
shown aggressive behavior toward:
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Please describe the other aggression.
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Please describe the
above incident(s):
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Please describe aggression incident(s).
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Does the cat spend time
indoors or outdoors?
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Please the indoors/outdoors activity of the cat.
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Has the cat ever destructively clawed
anything (furniture, drapes, carpeting)?
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Please check if the cat is descructive or not.
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Does the cat have and use a
scratching post or scatch box?
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Please check if the cat uses a scratch post or box.
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Has the cat ever urinated/sprayed/defecated
outside of its litter box while indoors?
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Please check if the cat has gone out of it's litter box.
Please describe the above incident(s):
Please describe the out of litter box incident(s).
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Has the cat ever killed rodents or birds?
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Please check if the cat has killed other animals or not.
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Does the cat sleep with you in bed at night?
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Please check if the cat sleeps in your bed or not.
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Please check all that apply:
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How often do you feed your cat?
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What sort of food does the cat eat?
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Any special dietary needs/preferences?
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Name and phone of vet:
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Dates of last vaccinations:
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Has your cat ever been tested for
Feline Leukemia Virus (FeLV)?
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Please check whether the cat has had a Leukemia test.
If Yes, was the cat found to be carrying the FeLV virus (FeLV+, aka FeLV positive)?
Please check the results of the Leukemia test.
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Has your cat ever been tested for
Feline Immunodeficiency Virus (FIV)?
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Please check whether the cat has had a FIV test.
If Yes, was the cat found to be carrying the FIV virus (FIV+, aka FIV positive)?
Please check the results of the FIV test.
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Does the cat suffer from any medical
problems? (If so, please describe
and include medications)
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Does the cat have any behavioral
problems or bad habits that a
new owner needs to be aware of?
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Does the cat have any particularly
interesting/endearing behaviors?
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Additional comments?
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Have you contacted the
HART office already?
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Please check if you have already contacted the HART Office or not.
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Do you authorize a vet check
by a HART representative?
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Please check if you authorize a vet check.
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Will you permit a home visit
by a HART representative
to see this cat?
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Please check if you authorize a home visit by HART.
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