ADMISSION INFORMATION |
| HOSPITAL
Name |
. |
| Hospital
Case Number |
|
| Name
of Staff Member Admitting Animal |
. |
| Date & Time |
Date |
|
| Time |
|
| Species |
Common name |
|
| Scientific
name |
|
| Finder Contact Details |
Name |
|
| Address |
. . |
| Telephone
number (s) |
. . |
| Email |
. |
| Signature
received for transfer of responsibility? |
Yes |
No |
|
| Sex |
Male |
Female |
Unknown |
|
| Age |
Mammal |
Infant |
Juvenile |
Adult |
|
| Bird |
Nestling / Downy |
Fledgling |
Subadult |
Adult |
| Reptile |
Hatchling |
Juvenile |
Adult |
|
| Amphibian |
Hatchling |
Juvenile |
Adult |
|
| Body
Weight (units = grams) |
. |
| Individual Identification Marks (Please specify type of mark and
site) |
Identichip |
. |
| BTO ring |
. |
| Darvic ring |
. |
| Other (Tattoo /
Scar) |
. |
| History |
Reason for
presentation |
. . |
| Duration in
captivity prior to presentation |
. |
| Details of any
treatment given prior to presentation |
. .
. |
| Details of any
food or water given prior to presentation |
. |
| Location
where animal was found |
Address |
. . |
| Postcode |
|
| Grid
reference |
|
| Geographical
points of details |
. |
| Contact
details of person finding the animal if different from above |
Name |
. |
| Contact
Details |
. |
DEATH / RELEASE INFORMATION |
| Release |
Time
of release |
Time of day |
. |
| Date |
. |
| Weather
conditions |
. |
| Details of
method of release (Hard / Soft and general description) |
. .
. |
| Overall Health
Status (e.g. healing wounds etc.) |
. |
| Number of
animals released (Sex and age ratio if applicable) |
. |
| Site of release
(Grid reference) |
. |
| Body weight on
release (units = grams) |
. |
| Body condition
on release |
Emaciated |
Thin |
Normal |
Fat |
Obese |
| Individual
Identification Marks (Please specify type of mark and site and re-enter any marks
etc. still present that were recorded on admission) |
Identichip |
. |
| BTO ring |
. |
| Darvic ring |
. |
| Other (Tattoo /
Scar) |
. |
| Transfer
to permanent captivity |
Name and
address of establishment |
. . |
| Description of
type of establishment (e.g. zoo, private garden, island on municipal lake etc.) |
. |
| Details
of person accepting responsibility for care. |
Name |
. |
| Address |
. . |
| Telephone |
. |
| Mobile |
. |
| Email |
. |
| Veterinary
Officer (details of veterinary surgeon responsible for the ongoing health care of the
animal) |
Name |
. |
| Address |
. . |
| Telephone |
.. |
| Signature
obtained (of the person accepting responsibility for care)? |
Yes |
No |
| Euthanasia
/ Died |
If
found dead (including if recorded after release): |
Was
the animal seen alive at any stage post-release? |
. |
| If yes, give description of post-release sightings. |
. |
| Circumstances of death |
. |
| Place
of death |
. |
| Estimated
time between death and discovery of animal |
. |
| If
euthanased: |
Reason
for euthanasia |
. |
| Type
of euthanasia |
. |
| Post
mortem performed? |
Yes |
No |
| Overall
findings of Post mortem examination (if performed) |
. .
. |
| Body
weight at Post mortem (units = grams) |
. |
| Veterinary
Officer responsible for overall care |
. |
| Staff
Member responsible for release / transfer |
. |
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