Owner Information

Date                          

Current Owner’s Name

Address 

City                                         State                                      Zip Code  

Daytime phone No.                                 Evening phone No.

Fax No.                                                     Email address

How did you learn about MPEBS?

Bird Information

Birds Name                                              Species

Sex (if known)                                         How and when verified

Date bird was acquired                       (Hatch date if known)

Acquired from

City                                          State

Is your bird hand tame                        Please explain

Authorization to Obtain Veterinarian Information

I hereby authorize the release of ALL medical records pertaining to the above listed bird(s) to authorized representatives of MPEBS.

 Signature                                                   Date

Veterinarian Information

(Obtain complete vet records and attach to this surrender form if possible)

Veterinarian name                                          Clinic

Address

City                                           State                             Zip Code 

Office phone No.                                      Fax No.

Last visit date Reason for visit

Is your bird banded?                                            band no

Is your bird micro-chipped?                               If so, what brand

Is your bird DNA registered? If so, with whom

Describe your birds overall physical condition:

Describe any injuries your bird has sustained:

 Describe any surgeries done and reason for the surgery:

List any medications your bird has been on and reasons prescribed: 

How often do you take your bird to the vet?

Does your bird have any medical/physical condition that requires treatment and/or specialized caging/play area?

Has your bird been treated for any diseases? Please describe

Current Diet

Please describe your bird’s current daily diet

List which food your bird currently eats, include specific name of food:

Seed

Pellets

Nuts

Treats

Cooked foods

Fruits and vegetables

Table foods

Junk foods

Favorite foods

Do you use vitamin supplements?                                         If so, in food or water

Has your bird ever been on herbal therapy?                         If yes describe 

Routine Care

Sleep Habits

Does your bird have night frights?

Bedtime

Wakes up at

Hours of sleep

Do you cover your bird’s cage? 

Separate sleeping cage

Bathing habits

Frequency

Likes or dislikes baths?

Playtime Activities?

Favorite toys?

Describe your birds play areas

Is your bird destructive?                                    Describe

How many hours a day does your bird spend outside the cage?

How many hours a day does your bird spend home alone?

Are there any other birds or pets in your home                      List

Does your bird interact with other birds?

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

Describe

Frequency of cage cleaning?

Behavior

List other members in your household, and how they interact with the bird

Who is your bird’s favorite person

Likes or dislikes children

Likes or dislikes visitors in the home

Who is your bird’s primary care giver

List any known behavioral problems (screaming, plucking, chewing, biting, etc)

List any changes within your household that may have contributed to the above behavior problems

When you go away for the weekend, or go on vacation, who cares for your pets?

Why are you considering placement of your bird with MPEBS?

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

Thank you for taking the time to complete this acquisition form in its entirety. The information provided will help us understand your birds’ needs. Please do not hesitate to call with questions or assistance in completing this form. If placement is the only alternative for you, contact your veterinarian for complete medical records and return with this form.

I, _________________________________ hereby donate to Montana's Parrot & Exotic Bird Sanctuary, the above listed bird(s) to be placed in the Montana's Parrot & Exotic Bird Sanctuary program.

I relinquish all claims to the above listed bird(s) and any future progeny.

Signature _______________________________________ Date_______________

Donor’s Name (please print)____________________________________________

The above-mentioned bird(s) has been accepted for Montana's Parrot & Exotic Bird Sanctuary by:

Signature _______________________________________ Date_______________

Accepted by (please print)_____________________________________________

Montana's Parrot & Exotic Bird Sanctuary

P.O. Box 719 ~ Whitehall, MT 59759 ~ 406-593-1150