Wildlife Intake Form
Thank you! We can't do it without you!
Customer Details:
Full Name
*
First Name
Last Name
Phone Number
E-mail
example@example.com
How did you hear about us?
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
Date given to Wild House Rescue:
-
Month
-
Day
Year
Date
Date animal was found:
*
-
Month
-
Day
Year
Date
Where did you find the animal? (approx location)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Did you provide any care to the animal: (Example: fed some food and offered water an kept on a heating pad; don't be scared to be right or wrong)
Any other details that you feel are important for us to know?
Would you like to upload any pictures that you took from your good deed?
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Date of initial exam:
-
Month
-
Day
Year
Date
Staff member:
First Name
Last Name
Species
Please Select
Red tailed hawk
Harris hawk
Coopers hawk
Bald eagle
Golden eagle
Turkey vulture
Black vulture
Swainson's hawk
Red shouldered hawk
Sharp shinned hawk
Northern harrier
Osprey
Crested caracara
Broad winged hawk
Mississippi kite
American Kestrel
Merlin
Peregrin falcon
Barn owl
Barred owl
Great horned owl
Burrowing owl
Eastern screech owl
Pygmy owl
Snowy owl
Raccoon
Opossum
Squirrel
Fox
Coyote
Cardinal
Blue jay
Other
Sex
Please Select
Male
Female
Unknown
Initial weight
Initial T/P/R
General Appearance:
Behavioral:
Integumentary:
Musculoskeletal:
Cardiovascular:
Respiratory:
Digestive:
Genitourinary:
Eyes:
Ears:
Neuroendocrine:
Lymph Nodes:
Feet/Pads:
Tail:
Nose:
Mucous Membranes:
Exam pictures:
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Should be Empty: