Pre-Adoption-Screening-Questionnaire – Town & Country Animal Hospital

Applicants Name*

First Last

Applicants Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email

Date of Birth*

How many humans live in your home?*

How many children live in your home?*

What are the ages of your children?*

How many animals live in your home? What kind?*

Does everyone in your household agree with this adoption?*

Yes
No

Does anyone in your family have pet allergies?*

Yes
No

Type of dwelling?*

House/Condo
Appartment

Do you ___?*

Rent
Own

If renting, are pets allowed?*

Yes
No

Landlords Name

Landlords Number

Do you have previous experience owning a special needs pet?*

Yes
No

If answered yes, please provide details:

Please provide your current veterinarians name and phone number for a vet reference:*

Are you financially ready to take care of the pet's routine/annual veterinary visits, medical treatment and emergency care if needed?*

Yes
No

You understand that due to Forrest's circumstances, he may not be declawed or ever become an outdoor cat*

Yes
No

Cats are very clean animals and require a clean litter box daily. This is key to preventing bad behaviors such as eliminating elsewhere in the home. Are you prepared to clean your cats littler box daily?*

Yes
No

Forrest is very playful, this is how he gets his exercise. To prevent him from clawing your curtains or other things he must have his own toys ( such as scratching posts, bed, balls, catnip). Are you willing to supply these items for your kitty?*

Yes
No

Are you ready to make a longterm commitment to this pet, knowing that a cat can live up to 20 years?*

Yes
No

Should circumstances ever force you to re-home Forrest, you promise to return him to Town and Country Animal Hospital?*

Yes
No

Electronic Signature*

Today's Date*

Monday	8:00am – 6:00pm
Tuesday	8:00am – 6:00pm
Wednesday	8:00am – 6:00pm
Thursday	8:00am – 6:00pm
Friday	8:00am – 6:00pm
Saturday	8:00am – 12:00pm
Sunday	Closed

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