Wildlife Admission Form

Wildlife Admission Form
Date Found

Month Day Year
Date
Brought in by:

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
How did you hear about us?
Would you like to be contacted after we examine the animal?

Yes No
Animal Information:
Species
Number of young (example: 3 baby rabbits)
Number of adult (example: 2 raccoons)
Condition: (describe)
Has the animal(s) bitten or scratched anyone?

Yes No
Have you fed or medicated the animal(s)?

Yes No
If yes, describe when, what, and how much:
Date Found

Month Day Year
Date
Time Found

: Hour Minutes AM/PM Option
Circumstances:
Is the animal:

Orphaned Injured Diseased
We do not charge for services rendered to wildlife if they will be released or turned over to a rehabilitator. If you care to leave a donation to our hospital to help cover our expenses, it would be appreciated, and 100 PERCENT will be used to care for the wildlife.
Treating Veterinarian:

Date:

Comments:
The animal:

Died Was euthanized Destroyed
DISPOSITION OF ANIMAL(S):

What rehabilitator(s) were called: Name(s):

Date called:

Time called:

Who called:

Released? Where: Date:

Date and time we contacted the person that brought in the wildlife:
Did you take a photo of the wildlife?

Yes No
Entered into the computer?

Yes No
Should be Empty: