Client Information
Would you like to receive reminders for your pet and updated pet news to your email? E-Mail Address : How were you referred to our practice? If referred by a friend please tell us their name so we can thank them for their referral. Form of Payment Pets Information
Pets Name Breed Birthdate / Age Color Sex : Male Neutered Male Female Spayed Female Unkown Previous Veterinary History
Date of your pet's last veterinary visit? Please contact my previous veterinarian for medical history. Name of previous veterinary practice Phone number of previous veterinary practice Appointment Details
Please write your ideal day of the week for an appointment and time of day. Reason for your pets visit? Avian Medical History
What type of cage does your pet have? What are the dimensions of the cage? H x W x L? Where is your cage located in the house? What kind of bedding is used? How often is the bedding changed? How often is the cage cleaned? Please describe cage accesories (bowl, toys, housing units) How often is your pet outside its cage? What kind of direct contact does your pet have with other pets? How often is your pet handled? Have there been changes at home or to environment? (new people/pets/toys/food) Does anyone smoke in the house? Do you use an ultraviolet light? Estimate the percentage you feed your bird: Pellets,Seed,Veggies,Fruit,Nuts,Dairy/Meat,Bread/Grain Do you give your pets vitamins or supplements? Please list: What is your pets source of water? (bowl/bottle) How often is it changed? Do you feed your bird from your own mouth or plate? Yes/No Does your pet bathe, how and how often? (water bowl/shower/misting) How often are your birds nails / wings / beak trimmed? How often, and who performs the grooming? Please list any previous medical problems: Is your pet on medication, or been previously prescribed medications? Please list: Has your pet had recent exposure to other pets? (grooming or boarding) YES/NO Has your pet been checked for intestinal parasites? Have you noticed a change in your pets droppings? If yes, please explain: Please list all changes and symptoms in your pet: i.e, weight loss, appetite loss, lethargy
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