Southeastern Raptor Center Patient Admission Form - Auburn University College of Veterinary Medicine

Today's Date*

Transporter Information

Transporter Name*

First Last

Organization (if applicable)

Transporter Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Transporter County*

Rescue Information

Date of rescue*

Is rescuer name same as above?*

Yes

If no, enter name of rescuer and phone number:

Rescue Location Address

Same as above. If no, enter rescue location including street address, city, county and state in fields below.*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Rescue Location County*

Reason for Rescue (please be as specific as possible, i.e., cat/dog, found in road, etc.):*

Have you offered the animal any food or water? If yes, what and when?*

Any other treatments given?*

Do you have a carrier/box that you would like to pick-up?*

Yes

If yes, you must request and legibly complete a label, and place it on the carrier before you leave. **All carriers/boxes must be picked-up within seven days or they will be discarded.

Would you like to be added to our mailing list?

Yes

Triage Hours

By dropping this animal off for admission with the Southeastern Raptor Center, I acknowledge that all raptor intakes will be triaged during the hours of 8 a.m. – 5 p.m. daily. No medical care will be provided outside of these hours. Animals surrendered to the Southeastern Raptor Center become the responsibility of the Southeastern Raptor Center, in accordance with all state and federal regulations, and the transporter has no rights pertaining to the animal.

Full Name*

By entering your name here, you acknowledge that you have read and understood the triage hours of the Raptor Center above.

Wild Bird

I acknowledge that this bird was found in the wild and is not owned or permitted for use by the individual dropping off. Owned/Permitted birds cannot be dropped off with the Southeastern Raptor Center.

Full Name*

By entering your name here, you acknowledge that you have read and understood that this bird was found in the wild and is not owned or permitted for use by you.

TRANSFERS ONLY

Organization Contact Name

Organization Contact Phone

Contact Email

Food Type/Amount:

Medications:

Other Treatments:

Exam Findings:

List all respiratory and neurological symptoms:

Has patient been tested for HPAI?

Yes

If yes, please list result.

HPAI Results:

**Please note we will not accept any patients with a positive HPAI test.**

Has your organization had any positive or suspect cases of HPAI in your facility?

Yes

Please elaborate on any positive or suspect cases of HPAI: