Owner's Name
(Required)
First
Last
Pet's Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
What species is your bird?
(Required)
What is the age of your bird?
(Required)
Do you know the gender (male or female)?
(Required)
Male
Female
I don't know
Where did you get your pet?
(Required)
How long have you owned them?
(Required)
How often is your pet handled?
(Required)
Does your bird mainly spend time inside or outside of the cage?
(Required)
Inside
Outside
Does your bird have reproductive history (egg laying,prolapse, etc.)?
(Required)
Yes
No
What type and size cage do you own?
(Required)
Where is the cage located in your home?
(Required)
What types of perches are in the cage?
(Required)
How often do you rotate the perches in the cage?
(Required)
Are bathing/spraying facilities provided?
(Required)
Yes
No
How often do you clean the cage and what do you clean with?
(Required)
Does your bird have regular exposure to sunlight? If so, how much?
(Required)
Does anyone in the household smoke?
(Required)
Yes
No
Does anyone in the household use any aerosolized products?
(Required)
Yes
No
Does anyone in the household cook with Teflon?
(Required)
Yes
No
What types of food do you offer and roughly howmuch of each type?
(Required)
How often do you feed your bird?
(Required)
Do you provide any nutritional supplements? If so, what kind and how much?
(Required)
How often is the water bowl cleaned/changed out?
(Required)
Do you have any other pets?
(Required)
Yes
No
What kind of other pets do you have?
(Required)
Does your pet live with any other birds in the same cage?
(Required)
Yes
No
Does your bird have any past medical history weshould know about?
(Required)
Yes
No
Please explain any past medical history
(Required)
Are there any current medical issues or concerns occurring?
(Required)
Yes
No
Please describe the complaint as well as how long it's been going on
(Required)