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? 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 (plants, branches or climbing structures) 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 If you feed insects, are they gut-loaded? Do you use a hygrometer (humidity meter)? If yes, what is the humidity? How is your pets cage / enclosure heated? (i.e, light, heating pad, heat rock) What is the temerature at your pets: Basking site? During the Day? During the Night? Do you use thermometers? If yes, where are they located? Do you use a full-spectrum (UVB) bulb? What kind of bulb is it? How often is it replaced? What is the light dark cycle? Does your pet get direct sunlight, not through a window? If your pet female, has it ever laid eggs?
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