Cat Intake Form Cat Intake Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Owner's Full Name * Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Email * Phone * Cat Name * Cat's Age * Date of Birth, if known Weight * Gender * MaleFemale Spayed/Neutered * YesNoUnsure Does the cat have a microchip? If so, please write the microchip number and company's name: * Breed(s) * Color(s) * Is the cat de-clawed? * AllFrontNot De-clawed When was the cat de-clawed? As a kittenAs an adultUnsureNever Has the cat bitten in the last 10 days? * YesNo Please explain if cat has ever bitten anyone? Reason for Surrender, if surrender reason is behavioral, please explain: * How long have you had this cat? * When does the cat need to be rehomed by? * Where did you acquire this cat? * From a shelterBreederFound as a StrayNewspaperFriend/relativePet StoreBorn in my houseOther Medical History Name, phone number and address of your veterinarian: Did the cat see a veterinarian at least once per year? * YesNoUnsure Has this cat been tested for Feline Leukemia? What were the results? * PositiveNegativeNever TestedUnsure Please explain if this cat has ever had surgery? Has the cat been diagnosed with and/or treated for any of the following? (check all that apply) * Upper Respiratory InfectionAllergiesHeart MurmurTumorsEpilepsy or SeizuresOrgan FailureThyroid DiseaseDiabetesUrinary Tract InfectionNoneUnsureOther Personality How would you describe the cat most of the time? (check all that apply) Friendly to FamilyVery ActiveClownCouch PotatoFriendly to VisitorsPlayfulAloofWithdrawnShy to FamilyTalkativeMore like a dogFearfulFearlessSolitaryPlayfulAffectionateIndependentShy to Visitor'sQuietLapCatOther How does the cat like to play? * Plays gently, does not usually use teeth or clawsLikes to play rough, may bit or scratchLikes to chase & pounce with variety of toysLikes to play hide & seekLikes to play in or around waterLikes to play with dogsLikes things that crackle, such as paper bagsWill fetch items like bottle caps or toysChases bugs or mothsLikes to play with other catsLikes to learn tricks for treatsNot interested in playOtherUnsure What areas of your home did the cat have access to?(check all that apply) * Indoors onlyIndoors at nightIndoors in cold weatherOutdoors in warm weatherIndoors with access to outsideOutdoors onlyGarage or BasementBarn or ShedScreened porchUnsureOther Where did the cat spend most of his or her time? (check all that apply) * BedroomKitchenLiving RoomGarage or basementAt the windowOutdoors onlyShed or BarnWhere people areUnsureOther Has this cat lived with another cat? What was the interaction like? (click all that apply) * Adored each otherPlayed togetherSniffed nosesGroomed each otherSlept near each otherIgnored each otherRough with othersFought with injuriesFought without injuriesUnsureGentle with othersCaused this cat stressPeacefully coexistedOtherN/A Has this cat has lived with dogs, how did they interact?(check all that apply) * Adored each otherPlayed togetherSniffed NoseGroomed Each OtherSlept near each OtherIgnored each OtherCat feared DogFought with injuriesFought without injuriesPeacefully coexistedCat tormented dogAvoided each otherUnsureOtherN/A Has the cat regularly been around children? * YesNoUnsure If yes, indicate what ages: 0-2 years3-5 years6-10 years11-18 years Explain cat and child(ren) interaction: * Is this cat more comfortable with: * WomenMenKidsTeenagersSeniorsLoves all peopleUnsure Does the cat do any of the following?(check all that apply) * Jump on CountersScratch FurnitureChew PlantsScratch Doors/CabinetsChew Personal ItemsClimb Curtains What is the cat's favorite brand of food? What type of treats does cat enjoy? * What type of treats does cat enjoy? * Which does this cat eat? * Dry OnlyCanned OnlyCombination of Dry & Canned How often is this cat fed? * Food always availableDesignated mealtimes Where does the cat use the bathroom * Litter box Inside HouseOutdoor Is the litter box: * CoveredUncovered Where is the litter box(s) located? * What type(s) of litter was used? * UnscentedScentedClumpingNon-ClumpingCrystalsClayPineNewspaper How often was litter box scooped? * Every day Every few days Weekly Rarely If other cats, how many shared a litter box? * OneTwo or moreMany cats shareMultiple boxes for multiple cats Has the cat lived with other animals before? * NoOther CatsDogsBirdsReptile, Amphibian, and Scaled AnimalsSmall Animal Please tell us any additional information about your pet that will help us place him/her in a loving home. * Initial *