New Small Mammal Appointment- Queens

Animal Medical Hospital
& Bird Clinic
&
Whitestone
Veterinary Care

The Animal Medical Hospital & Bird Clinic

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Please complete the form below if you would like to schedule an appointment for your small mammal at The Animal Medical Hospital & Bird Clinic. Our staff will call you shortly to schedule an appointment. If your appointment is an emergency please call the office directly.

Form - New Small Mammal Online Form- LI

Client Information

Name
First Name	Last Name

Address
Street Address


City	State/Province	Zip/Postal Code
,

Home Phone
Phone Type	Phone Number

Cell Phone
Phone Type	Phone Number

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?
Google
Yellow Book
Yellow Pages
Yahoo
In the Neighborhood
Referred by a friend

If referred by a friend please tell us their name so we can thank them for their referral.

Form of Payment
Credit Card or Debit Credit Card (we accept all major credit cards)
Cash
Cash or Credit depending on the total
Care Credit

Pets Information

Pets Name

Breed

Birthdate / Age

Color

Sex :

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?

Small Mammal 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?

List all foods and treats and estimate the percentage fed daily of each (hay/pellets/fruits/veggies)

Do you give your pets vitamins or supplements? Please list:

What is your pets source of water? (bowl/bottle) How often is it changed?

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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