FEATHERED FRIENDS SANCTUARY & RESCUE
Surrender Form & Questionnaire
Thank you for taking the time to complete this surrender form and questionnaire in its entirety. The information provided will help us understand your bird’s needs. Please do not hesitate to call with questions or assistance in completing this form. Please contact your veterinarian for complete medical records and return them with this form.
Contact Information
Bird’s Name ______Species ______
Guardian’s Name ______
Address______
City ______State______Zip ______
Phone # ______Cell # ______
E-mail address ______
Why are you considering surrendering your bird? ______
Would assistance with education or behavior modification be a possibility as a means for you to keep your bird? ______
Yes ______No ______Please explain ______
I hereby authorize the release of ALL medical records pertaining to the above listed bird(s) to representatives of this Shelter. ______
Instructions
I, ______hereby relinquish to Feathered Friends Sanctuary & Rescue, Inc. the above listed bird(s) to be placed in the Shelter adoption/placement program. I relinquish all claims to the above listed bird(s).
Relinquisher’s Signature ______
Print Relinquisher’s Name ______
Date ______
The above-mentioned bird(s) has been accepted for the Shelter by:
Shelter Representative’s Signature ______
Print Shelter Representative’s Name ______
Date ______
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Bird Information
Bird(s) Name ______Species______
Hatch Date ______Import Date if Wild Caught ______
Bird(s) Age ______Sex ______Method ______
When did you acquire your bird?______
Where did you acquire your bird? Pet Store __ Breeder __ Shelter __ Bird Club __ Private Party ___
Friend or Family member __ Gift ___ Other (explain) ______
Please provide contact information for your bird’s breeder, pet shop or previous guardian:
Contact name ______Store/Business ______
Address ______
City ______State ______Zip ______
Phone ______Fax ______
Health Information
Please obtain complete vet records and attach to this form.
Do you currently have an avian vet? ______If yes, please provide contact information.
Clinic Name ______Avian Vet’s Name ______
Clinic Address ______
City ______State______Zip______
Clinic Phone ______
How often do you take your bird to the vet? ______
When was your bird’s last vet visit? ______
What was the reason for this visit? ______
Is your bird banded? ______What is the band number? ______
Is your bird micro chipped? ______If yes, what brand? ______
Is y our bird DNA registered? ______If yes, with whom? ______
Describe your bird’s overall physical condition: ______
Has your bird ever sustained any injuries? ______If yes, please describe and give reason ______
Has your bird ever had any surgeries? ______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 medication? ______If yes, please list and give reason ______
Has your bird ever been on herbal or other alternative therapies? ______If yes, please describe: ______
Does your bird have any medical/physical condition that requires treatment and/or a specialized housing/play area? ______if yes, please describe: ______
Diet Information
Describe your bird’s current daily diet: ______
Favorite Foods: ______
List the foods your bird currently eats, including specific food names and brands:
Seeds: ______Pellets: ______
Nuts ______Treats ______
Cooked Foods: ______
Fruits & Vegetables ______
Other ______
Behavior
Is your bird comfortable being handled ______Please explain ______
______
Are there any other birds or pets in your home? ______If yes, please list (breeds etc.) ______
Does your bird interact with other birds or pets? ______If yes, please describe: ______
Does your bird like children? ______Please explain ______
Does your bird like visitors in the home ______Please explain ______
______
______
Does your bird have any known behavioral problems (e.g., screaming, plucking, chewing, biting, etc.)?
______If yes, please describe: ______