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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