Guardian name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary phone number *

(###)

###

####

Primary phone - able to text message?

Yes

No

Other phone number

(###)

###

####

Secondary contact name

First Name

Last Name

Secondary contact phone number

(###)

###

####

Secondary contact phone number - able to text message?

Yes

No

Is your pet microchipped? *

Unknown

Yes

No

Sex *

Unknown

Female

Male

Spayed/Neutered *

Unknown

Yes

No

Are the perches covered in sandpaper? *

Yes

No

N/A

Does your bird have access to any rubber toys? *

Yes

No

Unsure

Is the bird cage covered at night? *

Yes

No

Sometimes

Does your bird have free access around the home? *

Yes, always

Yes, sometimes

No, never

Does your bird have any cage mates? *

Yes

No

Is your bird allowed outside? *

Yes

No

Sometimes

Does your bird have a nest box? *

Yes

No

Sometimes

Do you spray your bird or give them access to a bath or shower? *

Spray

Bath

Shower

Both spray & bath

Both spray & shower

Both bath & shower

Other

None

Do you feed your bird pellets? *

Yes

No

Sometimes

Do you feed your bird seed? *

Yes

No

Sometimes

Do you feed your bird fresh fruit/vegetables? *

Yes

No

Sometimes

Does your bird leave any part of the diet uneaten? *

Yes

No

Sometimes

How do you give water? *

Bowl

Bottle

Both

Other

Any previous illnesses? *

Yes

No

Have you treated your bird with any medications? *

Yes

No

Please check all that apply *

If female, when was the last time she laid eggs?

Other birds/pets affected or ill

New birds introduced in the last 6 months

Change of type or source of food/water

Signs of weight loss

Decrease in activity level

Change in appetite

Change in water consumption

Droppings - change in colored (feces) part

Droppings - change in white (urate) part

Droppings - change in the the urine (clear) part

Droppings - passing undigested seeds

Vomiting or regurgitation

New lumps or bumps

Feather loss

Itchiness/skin irritation

Smokers in the household

Difficulty breathing

Noisy breathing

Eye discharge

Nostril discharge

Access to any potential toxins, such as toys or paint that may contain zinc/lead, toxic plants, foreign objects, branches sprayed with insecticide/herbicide, etc.

None of the above