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Irvine Animal Care Center

animalcare@cityofirvine.org

6443 Oak Canyon Irvine, CA 92618

949-724-7740

COMMUNITY SERVICES | Irvine Animal Care Center

Dog Owner Surrender Questionnaire/Medial History Consent Form

To provide the best care for your pet, it is necessary to have your pet's behavioral and medical histories available for review. Please complete the following informaiton so we may get to know your pet better an obtain their medical records from your veterinarian. Signing this form does not waive or reduce any pet fees past or present from the Irvine Animal Care Center. 

Gender

Household type


QUESTIONNAIRE

Is your dog spayed/neutered?

Are you the first owner?

Do you have other pets?

Where does your dog live?

Is your dog crate trained?

Is your dog house trained?

Has your dog had obedience training?

Does your dog go to the dog park?

Can your dog walk on a leash?

Has your dog ever seriously bitten or scratched anyone?

Is your dog relaxed when left alone?

HOUSE TRAINING

If you are experiencing problems with house training, answer the following questions.

Does your dog urinate, defecate, or both inside your home?

Has your dog been checked by a veterinarian to rule out medical problems that could cause this problem?


BARKING

If you are experiencing problems with barking, answer the following questions. 

Does your dog bark while on walks?

Does your dog bark at visitors?


DESTRUCTIVENESS

If you are experiencing problems with destructiveness, answer the following questions. 

Does your dog inflict injury on himself by:


ESCAPING

If you are experiencing problems with escaping, answer the following questions.

I acknowledge the above information is true to the best of my knowledge. I give permission to the Irvine Animal Care Center to contact my veterinarian and obtain my pet's medical history.

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The City of Irvine takes your privacy seriously. This form asks you to provide the City with certain personal information. Such information is being requested and will be utilized by the City for the specific and limited purpose of future City correspondence regarding the subject-matter of this form. Pursuant to Measure S, an initiative ordinance passed by City voters in 2008, all information provided on this form will be kept confidential. Unless you expressly indicate to us otherwise or unless compelled by a court order, it will not be shared with other agencies, businesses or individuals.