Capital Area Humane Society | New Home, New Hope
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Bird Surrender History
Owner’s Name: ___________________________ Phone Number: ________________________
Basic Information (Please check all that apply)
Bird’s Name: _____ ______ Nicknames? ______
Bird’s Current Age: ______ Bird’s Age When Acquired:
Is this Bird: ( Male ( Female Confirmed by blood or DNA test? ( NO ( YES
Name of Veterinary Clinic bird has been to:
First and last name on the account at the vet’s office: _
Last time bird was seen by the vet:
Has your bird ever had its wings clipped? ( NO ( YES
Why are you surrendering your bird?
← Moving ( Too expensive ( No time ( Too noisy
← Behavior issues (please explain):
← Other: (please explain) ________________________________________________
How did you obtain the bird?
← Adopted from Capital Area Humane Society. If so, when?
← Breeder ( Gift
← Friend, neighbor, or family member ( Other:
← Pet store
← Adopted from (shelter, rescue, other organization):
Housing Information (Please check all that apply)
How was the bird housed?
( Cage only ( cage and free range
← Free range only ( Other: __________________________________________
Do you take your bird outside? ( Yes ( No
Has your bird ever shared a cage with another bird? ( Yes ( No
Exposure to People/Animals (Please check all that apply)
Children ( Lived with ( Visited with ( Never been around
Cats ( Lived with ( Visited with ( Never been around
Dogs ( Lived with ( Visited with ( Never been around
Other birds ( Lived with ( Visited with ( Never been around
How does the bird behave and/or interact with the following?
|Adults |Young Children |Older Children |Strangers |
|( Friendly |( Friendly |( Friendly |( Friendly |
|( Playful |( Playful |( Playful |( Playful |
|( Plays Rough |( Plays Rough |( Plays Rough |( Plays Rough |
|( Cuddly |( Cuddly |( Cuddly |( Cuddly |
|( Vocal |( Vocal |( Vocal |( Vocal |
|( Tolerates |( Tolerates |( Tolerates |( Tolerates |
|( Shy |( Shy |( Shy |( Shy |
|( Hides |( Hides |( Hides |( Hides |
|( Aggressive |( Aggressive |( Aggressive |( Aggressive |
Feeding Information (Please check all that apply)
What type of food does the bird eat?
( Bird seed Brand:
( Pellets Brand:
( Fruits/Veggies Favorites: _________________________________
( Other: (please list): ________________________________
How often/much is the bird fed?
( Once daily Amount: Time Fed: _________
( Twice daily Amount: Time Fed: _________
( Free Fed
Would you describe the bird as a picky eater? ( Yes ( No
Does the bird have any favorite food/treats? _____ _________
Play/Daily Routine Information (Please check all that apply)
Does the bird talk? ( Yes ( No
What does the bird say? ________________________________________________________
Is the bird hand tamed? ( Yes ( No
Does the bird “Step up” on command? ( Yes ( No
Is the bird stick/towel trained? ( Yes ( No
Does your bird have any favorite toys? _______________________________________________
What time do you put the bird to bed? _____________ Do you cover the cage? ( Yes ( No
Behavioral Information (Please check all that apply)
Has the bird ever been aggressive with anyone? ( Yes ( No
If yes, please explain: ______________________________________________________________________________
______________________________________________________________________________
How often is the bird handled?: ( Daily (Weekly ( Never
Is the bird afraid of any of the following?
← Vacuum ( Women ( Children
← Nail clippers ( Carriers
← Men ( Bathing
← Strangers ( Loud noises
← Other animals ( Other:
How does the bird behave when it is afraid?
( Hides ( Screams ( Bites ( Other: ______________________________
Overall how would you describe the bird?
← Calm ( Friendly ( Hyper
← Cuddly ( Curious ( Playful
← Confident ( Fearful ( Outgoing
← Vocal ( Shy ( Aggressive
← Other:
Please list any additional information you would like us and/or any potential adopters to know about the bird:
__________________________________________________________________
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