~Please fax this form to 517-265-3837 or email to ilovepets@tc3net.com. Thank you!~

LENAWEE HUMANE SOCIETY                               Date___/___/___Staff Initials______

PRE-ADOPTION QUESTIONNAIRE                    Animal Name____________LHS#______

Regarding your home, do you: (Please check only one)

                         ___Own a house                                      ___Rent a house/apartment

Landlord/Community Name_____________________________________ Phone # (    )________

                   **Please be advised that it is our policy to have landlord approval prior to adoption completion**

How many children live in your household?_____ Ages?______________ How many adults?______

Does anyone in your household have known allergies to any animals?__________________

Please list all the cats and dogs currently living in your home. If none, please check here_____

         Animal                                                   Kept Inside     Adopted     Up to Date on               Vet              Dates of

 Name & Species    Age   Sex     Altered     or Outside     from LHS    Annual Vaccines     Verification     Last Vaccines

____________ ___ ___ _______ _________ _______ ____________ ____________________

____________ ___ ___ _______ _________ _______ ____________ ____________________

____________ ___ ___ _______ _________ _______ ____________ ____________________

____________ ___ ___ _______ _________ _______ ____________ ____________________

____________ ___ ___ _______ _________ _______ ____________ ____________________

Who is your current veterinarian? Name/Clinic_____________________ Phone # (    )__________

List two character references that can tell us how you are with animals. Please list only one family member,

and you may not list a person visiting the shelter with you today.

Office Use Only

1._________________________ Phone # (    )__________ [_______________________________]

2._________________________ Phone # (    )__________ [_______________________________]

If your new pet were to become seriously ill or injured and needed expensive veterinary treatment, what

would you do?____________________________________________________________________

What will happen to your new pet in case of emergency, or if you go on vacation?__________________

Please list the dogs and cats you have had within the last five years, but no longer live in your home:

_________________ ___ ______ _______________________ ____________________________

_________________ ___ ______ _______________________ ____________________________

_________________ ___ ______ _______________________ ____________________________

_________________ ___ ______ _______________________ ____________________________

_________________ ___ ______ _______________________ ____________________________

Who was your previous veterinarian if not same as above? Name/Clinic__________________________

Why do you want to adopt this animal? (Please check all that apply)

___For a companion             ___To breed                   ___To guard home/property

Where will this pet spend most of its time?

___Inside the home             ___Outside in yard            ___Outside in kennel/barn

When outside, how will this pet be restrained?

___Free roaming                 ___Fenced yard                ___Tie-out cable/chain

Once adopted, under what conditions could you no longer keep this pet? (Please check all that apply)

___Soils in house                 ___Chews on furniture      ___Noisy/rambunctious

Please be advised that every animal goes through an adjustment period when introduced to a new

environment, and your new pet may not adjust for several days or weeks. What will you do if your

new pet does not adjust to its new surroundings right away?_____________________________

Do not enter this adoption half-heartedly. Please spend enough time with the animal you wish to adopt to really get to know it. You are encouraged to bring in all family members, including other pets, to meet and interact with the animal you wish to adopt. The Lenawee Humane Society offers all adopters the option of temporarily fostering an animal if you are uncertain about its behavior at home, or how other family members will respond to a new pet. Please ask your adoption counselor about this process.

Most animals live to be at least ten (10) years old, and all need to visit a veterinarian at least once yearly to stay healthy throughout their lives. You can expect to spend $100-$200 every year per pet on routine veterinary care alone. Your new pet will be required by law to be spayed/neutered within thirty (30) days of adoption (mature animal), or when it reaches maturity (six months of age) if it is not already altered at the time of adoption. Are you willing to make this commitment?______

If the Lenawee Humane Society has reason to believe an adopted animal is not being cared for properly, or if any articles of the Adoption Contract are not being followed, we reserve the right to investigate and reclaim the adopted animal. Do you have any objections to this?______

We like to follow up on our adoptions, and sometimes call our adopters to ask about their adoption experience at our shelter and how their new pet is adjusting to its new home. Do you object to a Lenawee Humane Society representative phoning your home concerning an adoption?______

We ask that you have your new pet examined by your veterinarian within the first fourteen (14) days of adoption to establish a program of veterinary care and determine its current state of health. Please understand that after your adoption is finalized, your adoption fee will only be refunded if your veterinarian determines within fourteen (14) days of adoption that your new pet has a potentially fatal disease or birth defect upon examination. Proof of this finding is required in writing from your veterinarian. Your adoption fee will not be refunded for any other reason. You are given an opportunity to temporarily foster your new pet prior to finalizing an adoption. Do you understand and agree to the terms regarding adoption fee refunds?______

Signature_______________________________________________________Date___/___/_____