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Exotic Pet Patient Registration

Pet Name(Required)

Last Name

Species/Breed(Required)

Gender(Required)

Age(Required)

Length of Ownership(Required)

Where from?

Purpose of Visit(Required)

(e.g. wellness exam, weight loss, skin issue)—with onset date

Previous Veterinary Care(Required)

Yes

If yes, list clinic, date, records available?

Current Medications / Supplements

(name, dosage, frequency, brand)

Medical History

(illnesses, injuries, parasites—past or present)

Diet & Nutrition

All Foods Offered

(including brand, type, amount, frequency)

Housing & Husbandry

Enclosure Type & Location

(indoor, outdoor, dimensions

Substrate

(type, change frequency, cleaning method)

Temperature & Humidity

(day/night temps, measurement tools, levels, heat source)

Lighting

(UVA/UVB or natural; bulb type; daily duration; replacement schedule)

Cleaning Schedule & Methods

(habitat, dishes, disinfectants)

Bathing & Hydration Methods

(e.g. soak, mist; frequency)

Enrichment

(toys, perches, foraging devices, rotations)

Exercise / Roaming

(how often, supervised, outside enclosure)

Other Pets at home?

(Do they interact at all? Is the enclosure shared with another animal?)

FOR BIRDS

Do you use Teflon or nonstick pans in the house?

Yes

Are there any candles or aerosols near the enclosures

Yes

Observations of Health & Behavior

Appearance of Droppings

(frequency, color, consistency, odor)

Respiratory or Other Signs

(sneezing, discharge, tail bobbing, fluffed appearance)

Skin / Fur / Feather Issues

(molting, plucking, lesions, shedding pattern)

Mobility & Behavior Changes

(lameness, weakness, behavioral shifts)

Is your pet used to being handled?

Or do they prefer not to be touched?

Additional Questions or concerns you think we should know

If you are visiting this office for the first time, it is important that we receive all the prior and appropriate medical history for your pet. This information could provide useful information to properly treat your animal. It is recommended you contact your previous veterinarian and have this information emailed to our office at [email protected].

I am the owner or agent of the above stated animal and give the authority to execute this consent. I hereby authorize the veterinarian to examine, treat, and prescribe for the above-described pet. I assume responsibility for all charges incurred in the care of the pet. I also understand that all professional and medication fees are due at the time service is rendered.

Owner Name(Required)

(Print)

Date(Required)

Owner Signature(Required)