Date:

*

Contact Information

First Name

*

Last Name

*

Address

*

State

*

City

*

Zip Code

*

Phone Number

*

Email

*

Surrendered Bird Information

Bird's Name

*

Species

*

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

*

Species

*

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.

*

Date:	*
* Contact Information
First Name	*
Last Name	*
Address	*
State	*
City	*
Zip Code	*
Phone Number	*
Email	*
* Surrendered Bird Information
Bird's Name	*
Species	*
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	*
Species	*
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.	*

Bird Surrender Form

Contact Information

Surrendered Bird Information

Current Diet

Veterinarian Information

Routine Care

Behaviorial Information

VETERINARY INFORMATION RELEASE: