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Date

Owner's Name

Account Number

Phone

Email

Pet Information

Please fill to completion.

Pet's Name

Species

Avian
Reptile
Small Mammal
Other

Please specify species

If female bird/reptile, have they ever laid an egg?

Yes
No
Not Applicable

Laid Egg: Yes

Please specify when, and how often your pet has laid an egg.

Where was your pet obtained?

When was your pet obtained?

Are there other pets in the household?

Do they interact with this pet?

Cage Mates?

Please specify

Husbandry

Please include details.

Type of housing / cage description

Substrate / cage lining

Cage contents (toys, perches, dishes, etc.)

Heat source / hours per day (if applicable)

Highest Temperature (°F)

Lowest Temperature (°F)

Type of thermometer / gauge

Humidity (%) (if applicable)

UVB Bulb (if applicable)

Last time bulb was changed

Light source / hours per day (if applicable)

What is the location of the cage in the household?

How often is the cage cleaned?

How many hours per day is the pet caged?

Does the pet ever go outdoors?

How often is the pet handled?

Daily
Weekly
Occasionally
Never

What type of activity?

How often?

Any type of grooming?

Diet

Please specify the type of food for each question, the amount given, and how often the pet receives it.

Staple diet (pellets, seeds, mis, etc.)

Is your pet given hay? (if applicable)

What type?

Access at all times?

Fresh / frozen foods

Fruits / vegetables

Treats / supplements

Do you dust food or gut load? (if applicable)

Frequency and amount of food given / water changed?

Medical History

Please be as detailed and accurate as possible.

Coughing / Sneezing

Vomiting / Diarrhea

Stools normal / abnormal

Urination normal / abnormal

Previous medical issues?

Currently taking any medications?

Any allergies to medication(s)?

On any heart worm or flea prevention? (if applicable)

Current on Rabies and Distemper? (if applicable)

Date last given?

Any vaccination reaction?

Acknowledgement

By filling out this form I give authorization for examination of the pet herein specified.