Wildlife Admission Form

Wildlife Admission Form
Brought in by:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
How did you hear about us?
Would you like to be contacted after we examine the animal?
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?
Have you fed or medicated the animal(s)?
If yes, describe when, what, and how much:
Date Found

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time Found

Hour Minutes

AM/PM Option
Circumstances:
Is the animal:
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:
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?
Entered into the computer?
Should be Empty: