Avian Name
Email *
Common or Scientific Species Name *
Date of Birth *
Age *
If other, please specify *
How long have you had this bird? *
Where did you obtain this bird? *
Details
When did your bird last molt? *
How often has your bird been molting? *
Details
Details
If yes, please provide species
Details
When did you bring your last bird home? *
Do you have any concerns about your bird? If so, how long have these issues been present? *
Has your bird had any previous health issues? If so, please explain: *
Has your bird received any treatment in the last 30 days? If so, please provide details (Medication name, dosage, how often, duration): *
Have you noticed any changes in your bird’s behavior? If so, please explain: *
Has anyone in your household (animals included) had any illness in the last 30 days? *
How often do you feed your bird? *
Please indicate what foods and amounts are provided to your bird. *
If other, please specify *
Brand or type *
Amount *
If yes, how much and how often? *
If other, please specify *
How often? *
How often is the water changed? *
Details
Have you noticed any changes in eating/drinking behavior? Please provide details.
Have you noticed any changes in droppings? (Fecal Material, Urine, Urates) Please provide details.
Details
What is the cage made of? *
Cage size? *
What type of bedding is used? *
If other, please specify *
How often is the cage cleaned? *
What cleaner/disinfectants are used? *
Details
How often/long?
Brand
What is your bird’s light/dark cycle?
Have there been any changes in your bird’s environment in the last 3 months? If yes, please explain:
PLEASE INCLUDE ANY OTHER COMMENTS OR DETAILS BELOW
