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Please fill out this form to the best of your ability. Your answers will help us get to know your pet and give us some background information prior to the intake assessments. This will help us better understand your pet during the assessments.

Owner Information

Would you like to be on our mailing list?

Dog Information – General

Is your dog microchipped?
Is your dog a return?

Dog Information – Medical

Has your dog been coughing, sneezing or vomiting within the last week?
Does your dog have any known allergies?
Is your dog currently on any medications?
Has your dog had any prior surgeries, OTHER THAN spaying/neutering?
Has your dog experienced any physically traumatic injuries?

Dog Information – Behavioral | Sociability

How does your dog respond to the following people? (Check all that apply)

Strangers (Adult)
Strangers (Children)

How does your dog interact with the following animals? (Check all that apply)

Has your dog ever been involved in an animal fight?

Dog Information – Behavioral | Training & Manners

How would you describe your dog’s energy level?
What type of play does your dog like?

How does your dog react if you get near his/her toys/food or try to take them away?

How does your dog act around a swimming pool/water?
How does your dog react to bathing/grooming?
How does your dog react to car rides?
How does your dog act at a veterinarian’s office?
Does this dog have any of the following problem behaviors? (Please explain below)
Is your dog housebroken?
Is your dog crate trained?
What words does your dog understand (check all that apply)?

Pet Relinquishment Fee Disclosure and Liability Wavier

Thank you for giving the Mary S. Roberts Pet Adoption Center the opportunity to assist you in rehoming your pet. We are a private nonprofit organization that receives no city, state or federal funding. We rely solely on revenue that we generate to care for pets while they are in our care. On average, the cost of care for ONE DAY is $25/pet. Our pet relinquishment fees help us to offset these costs. For adult animals the relinquishment fee is $150 for the first pet and $25 for each additional pet. For litters of puppies/kittens the relinquishment fee is $50 for the first pet and $5 for each additional littermate.

By signing below, I certify that:

  • I am the legal owner of the pet(s) above or that I have full authority to surrender the pet(s) above on behalf of the legal owner
  • I agree to have my animal(s) assessed for intake according to the standards set by the Mary S. Roberts Pet Adoption Center, including a medical assessment that may or may not include diagnostic testing (skin scraping, blood draws/tests, black lighting, etc.), and that the Mary S. Roberts Pet Adoption Center staff maintains the right to refuse or not complete the intake assessment should the animal(s) pose a risk to the Mary S. Roberts Pet Adoption Center employees, volunteers, guests or itself
  • I agree to the pet relinquishment fees disclosed
  • I understand that in the event of a bite incident the Mary S. Roberts Pet Adoption Center staff is required by law to submit a bite report to the Riverside County Department of Animal Services and that my animal(s) will need to be held for a 10-day rabies quarantine of which the location will be determined by the Riverside County Department of Animal Services
  • I hereby agree and covenant for myself, my heirs, executors, administrators and anyone else who may claim on my behalf, not to sue, and I hereby waive, release and discharge the Mary S. Roberts Pet Adoption Center and its directors, officers, volunteers, employees and agents from any and all claims, causes of action and demands of any nature, whether known or unknown, against the Mary S. Roberts Pet Adoption Center arising out of or in connection with or in any way related to our pet relinquishment program, even though the liability may arise out of negligence or carelessness on part of the individuals or entities so released

Get in Touch

Telephone: (951) 688-4340
Fax: (951) 359-6417
Write Us: Email Form
Find Us: Map & Hours
Staff: Login

6165 Industrial Avenue
Riverside, CA 92504


Copyright © 2019 The Mary S. Roberts Pet Adoption Center. All Rights Reserved.
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