Exotic Rehoming Form - Colorado Animal Rescue

My Information

Date*

Name*

First Last

Physical Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mailing Address (if applicable):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone:*

Alternate Phone:

E-mail:

Animal Information

Name of pet:*

Type of animal:*

Specific Breed or Type of Bird:*

Specific Breed or Type of Small Mammal:*

Specific Breed or Type of Reptile:*

How old is this animal?*

Number of days, weeks, months, or years:*

What is the gender of this animal?*

Does the animal have any other alterations (i.e., "de-scented," etc.)?*

No
Yes
Unsure

Please Explain:*

How long have you had this animal?*

Number of days, weeks, months, or years:*

Where did you obtain this animal? (Petco, Other Shelter, This Shelter, Friend, Family, etc.)*

Is this animal able to be handled?*

No
Yes

Has the animal ever been seen by a veterinarian?*

No
Yes

Name of Veterinary Hospital, Doctor, and Hospital's Location:*

Does the animal have any health problems?*

No
Yes
Unsure

Has the animal been treated for this problem?*

No
Yes

Please explain:*

Is this animal current on vaccines? (Distemper, Special Rabies)*

No
Yes
Unknown

Is the animal currently ill?*

No
Yes

Why are you surrendering this animal? (Please be as detailed as possible)*

Please describe the symptoms and when they first showed signs of being ill. (Examples: Lethargy, change in appetite, skin problems, injury, breathing difficulties, nasal discharge, etc.)*

Has the animal bit anyone?*

No
Yes

Please explain:*

Hidden

Bird Info Section

How was sex determined?*

Does the bird have any identification? (Tattoo, Microchip, Band, etc.)*

No
Yes
Unsure

Form of identification:*

Do you have other birds in the home?*

No
Yes

What type and when were they obtained?*

How is this animal housed? (Check all that apply)*

What are the dimensions of the indoor cage?*

What are the dimensions of the outdoor cage?*

What are the dimensions of the garage cage?*

Please describe housing:*

How many hours of darkness does the bird have each day?*

What material do you use for the bottom of the cage/enclosure?*

How do you clean your pet's cage and how frequently do you clean?*

Was this bird housed with any other birds?*

No
Yes
Unsure

Please list quantity and types:*

Do you provide toys for your bird?*

No
Yes

Please list quantity and types:*

How do you provide your pet with water?*

Please describe:*

Type of diet:*

What kind/brand of formulated diet?*

What kind of vegetables?*

What kind of fruit?*

What kind/brand of seeds?*

What kind/brand of vitamins and how are they given?*

Please explain*

Please describe any recent changes to diet or environment. (If applicable)

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Small Mammals

How is this animal housed? (Check all that apply)*

What are the dimensions of the indoor cage?*

What are the dimensions of the outdoor cage?*

What are the dimensions of the garage cage?*

Please explain housing:*

What material do you use for the bottom of the cage/enclosure?*

How do you clean your pet's cage and how frequently do you clean?*

How do you provide your pet with water?*

Please describe:*

Type of diet:*

What kind/brand of formulated diet?*

What kind of vegetables?*

What kind of fruit?*

What kind/brand of treats?*

What kind/brand of hay?*

What kind/brand of vitamins and how are they given?*

Please explain:*

Please describe any recent changes to diet or environment. (If applicable)

Hidden

Reptile

How was sex determined?*

Do you have other reptiles in home?*

No
Yes

Please explain:*

How is this animal housed? (Check all that apply)*

What are the dimensions of the indoor cage?*

What are the dimensions of the outdoor cage?*

What are the dimensions of the garage cage?*

Please explain housing:*

Please list any cage furniture:*

Please list bedding or substrate type:*

Heat Source:*

Please list the average cage temperature: (Farenheit)*

Please list the level of humidity in the cage:*

Do you provide full spectrum light?*

No
Yes

Please describe bulb and brand:*

How do you clean your pet's cage and how frequently do you clean?*

How do you provide your pet with water?*

Size of dish:*

How often do you mist?*

Please explain:*

Type of diet:*

What kind of insects/worms?*

What kind?*

What Kind/Brand of formulated diet?*

What kind of fruit?*

What kind of vegetables?*

What Kind/Brand of supplements/vitamins and how are they given?*

Please explain:*

Please describe any recent changes to diet or environment. (if applicable)

How frequently do you soak or bathe the animal? (if applicable)

Date of last shedding: (if applicable)

Additional Comments:

E-Signature

Statement of surrender: By signing below I certify that I do not own the animal/s being relinquished and that the animal/s has not bitten anyone in the last ten days or the length of time in my custody unless otherwise stated above. I hereby relinquish all rights of ownership to this animal/these animals to Colorado Animal Rescue, and agree that the disposition of this animal/these animals be at the discretion of the animal shelter. I understand that the animal shelter has the right to not release further information regarding the disposition and status of the animal/s.

Your Full Name:*

By typing your name in the box below, you attest that you have read and fully understand this form and certify that all information is true to the best of your knowledge.