First & Last Name

Address Line 1

Address Line 2

Telephone number

Email address

Todays Date

Species

What is the reptile's name?

Is it tame? (leave unchecked if not)

Wild animal?

Stray animal?

How old is it?

Male

Female

unknown

How large is it?

Explain why you are surrendering this animal

Where did you get it originally?

How long have you had this reptile?

Has it ever bitten anyone? If so, explain.

What vet care has it received?

Who is the veterinarian used for this reptile?

Please give the contact info for this vet.

Describe the cage this reptile was in.

Are other reptiles in the same household?

Specifically, what is it eating? (Kale, not "veggies")

How much does it eat?

How often is it fed?

How often is it handled?

Please tell us anything else that we need to know about this reptile.

Please enter your name as an electronic signature

Please indicate the amount of donation you intend to provide. While surrenders are not denied due to lack of donation, you are expected to provide something towards our cost of caring for your animal. We are a home-based rescue, and operate out of our own pockets. We receive no outside funding. You will have the opportunity to use Paypal on the next page to make a donation with your credit card, checking account, etc., or you can bring a cash donation at the time of surrender.

Considering that we have to pay the electric, oil, and food bills, please be prepared to make a donation of some amount. We appreciate every penny we get, and it all goes towards the animals.

YES

NO