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.

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