Name:

Phone Number: ( )

Address:

City, State, Zip:

E-mail Address:

Type of Bird Wanted (Please specify a species, individual names, or character traits):

Name and Phone number of your Avian Veterinarian:

Have you ever owned birds before?    

How many other birds do you have or have had?          Do you still own? 

If yes, what type(s)?

If no, please describe what happened:

Please describe any other pets that are in your home, including type, species, age, and temperament:

Other pets' Veterinarian’s name and phone number:

Do you live in a: Single family home Duplex Apartment Complex Mobile home

Landlord/Manager’s name and phone number:

Do you or does anyone living in your home smoke?  No    If Yes, where do they smoke?

Do you have allergies to dust or other airborne particles?  No    If yes, then please describe:  

How many children do you have?      Their ages?

Who else is in your household?  Who else will be regularly interacting with your bird?

Who will be the primary caregiver of the bird?

How many hours a day are you away from home?

How many hours a day do you have to spend with your bird(s)?

How many hours a day are/will the bird(s) allowed out of their cage(s)?

Please describe the cage you will have for the new bird, including size, type, and age:

What do you feed your bird(s)?

Who will take care of your bird(s) if something happens to you or the primary caregiver?






3053 Beechwood Ind. Ct., Suite 1 ● Hubertus, WI 53033 ● 262-628-3719 ● www.centerforavianrehab.org ● cntrforavianrehab@sbcglobal.net