Date:

Contact Information

First Name

Last Name *

Address *

State *

Zip Code *

City *

Phone Number *

Email *

Surrendered Bird Information

Bird's Name *

Species *

Subspecies or coloring *

Age (Hatch Date if known)

Sex

Female
Male
Unknown

If known, how and when was the sex verified?

When did you acquire the bird?

Where did you acquire the bird?

What is the bird's history?( Previous owner, reason previous owners couldn't keep) *

Bird's favorite phrases/ games

Current Diet

Describe your bird's current diet. Please be as specific as possible, Include brand name. *

Does your bird have favorite treats or foods?

Are there any foods that your bird dislikes or has a negative reaction to?

Do you have vitamin supplements?

Veterinarian Information

Do you currently have an avian veterinarian?

Clinic's Name

Avian Vet Name

Address

City, State, Zip Code

Phone Number:

How often did you take the bird to the vet?

When was your bird's last vet visit?

What was the reason for this visit?

Is the bird banded?

If yes, what is the number?

Is your bird micro-chipped?

If yes, what is the brand?

Describe your bird's overall physical condition. *

Has your bird ever sustained any injuries?

If yes, please describe:

Has your bird ever had surgery?

If yes, please describe and give reason:

Has your bird ever been treated for any diseases?

If yes, please describe:

Has your bird ever taken any medications?

If yes, please list and give reason:

Has your bird ever been on herbal or other alternative therapies?

If yes, please describe:

Routine Care

Who is your bird's primary caregiver?

Are you donating the cage with the bird?

If yes, please describe the cage:

What type of perches does your bird prefer?

Describe some of your bird's favorite toys.

Please describe your bird's playtime activities.

Describe your bird’s sleeping habits, including bedtime, wake-up time, nap times, and hours of sleep each day:

Does your bird ever have night frights?

Do you cover your bird’s cage at night?

Describe your bird’s bathing habits, including frequency, likes, and dislikes:

Describe your bird’s play area(s):

How much time does your bird spend outside the cage each day?

How do you provide daily exercise and entertainment for your bird?

How much time does your bird spend alone?

Do you leave the radio, TV, or other audio/video on for your bird?

Behaviorial Information

Is your bird destructive?

If yes, please describe:

Is your bird hand tame?

Does your bird interact well with other birds?

If no, please describe:

Who is your bird’s favorite person?

Does your bird interact well with other household members?

If no, please explain:

Does your bird like children?

How does your bird react to strangers?

Does your bird have any known behavioral problems (i.e., screaming, plucking, aggression, etc.)?

If yes, please describe (Please be as honest as possible. It will not affect our acceptance of your bird, but it will help us in understanding his/her behavior, and will enable us to provide the best placement situation):

Why do you feel surrender of your bird is your only option? *

Would assistance with education or behavior modification be a possibility as a means for you to keep your bird?

How did you learn about St. Louis Avian Rescue?

Additional comments or information you think we should know?

VETERINARY INFORMATION RELEASE:

I hereby authorize the release of ALL veterinary medical records to representatives of St. Louis Avian Rescue for the following bird(s). Bird Name *

I, hereby donate to STAR - St. Louis Avian Rescue, the above listed bird to be placed in this organization’s adoption program. I relinquish all claims to the above listed bird. This form is complete and true to the best of my knowledge. *

A copy of this document may be provided to the adopting party. If you wish us to withhold your name and contact information. *

All information listed above is true and accurate to the best of my knowledge. *

Signature Instructions:

Use your mouse to sign your name by clicking and holding it down as you write if not using a touchscreen device.

Signature

Bird Surrender Form

Contact Information

Surrendered Bird Information

Current Diet

Veterinarian Information

Routine Care

Behaviorial Information

VETERINARY INFORMATION RELEASE: