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Exotic Patient Information Form
Thank you for providing information about your pet!
This form helps us understand your animal’s environment, diet, and care so we can provide the best
medical support possible.
Current Date:
*
Client Name:
*
Client's Date of Birth:
*
Address:
*
Phone Number:
*
Patient Name:
*
Species:
*
Breed (if known):
*
Sex:
*
Sex:
Male
Female
Unknown
Spayed/Neutered
Age-Hatch Date/Birth Date:
*
How long have you owned this animal?
*
Where did you obtain your pet?
*
Where did you obtain your pet?
Breeder
Pet Store
Rescue
Other
Housing & Habitat
Type of enclosure:
*
Type of enclosure:
Tank
Cage
Aviary
Free-range
Other:
Enclosure dimensions:
*
Substrate or Bedding type:
*
Temperature Range:
*
*
Humidity range (if applicable): %
*
Heat/Light sources used:
*
Heat/Light sources used:
UVB Light
Heat Lamp
Ceramic Heater
Other:
Lighting schedule (hours on/off):
*
Frequency of cleaning:
*
Diet & Nutrition
Primary diet:
*
Brand or type of food (if applicable):
*
Feeding frequency:
*
Supplements provided (vitamins, calcium, etc.):
*
Recent changes in diet:
*
Recent changes in diet:
A
Yes
B
No
If yes, please describe:
*
Social Environment
Is your animal housed alone? ☐
*
Is your animal housed alone? ☐
A
Yes
B
No
If no, list the number and species of cage/tank mates:
*
Have there been any recent introductions or separations?
*
Have there been any recent introductions or separations?
A
Yes
B
No
If yes, describe:
*
Behavior & Activity:
Normal activity level:
*
Any changes in behavior, appetite, or activity?
*
Any changes in behavior, appetite, or activity?
A
Yes
B
No
If yes, please describe:
*
Medical History
Previous veterinary visits:
*
Previous veterinary visits:
A
Yes
B
No
If yes, date of last visit:
*
Known medical conditions:
*
Current medications or treatments:
*
Recent injuries or illnesses:
*
Additional Notes or Concerns:
*
Signature:
*
Signature
Date:
*
Submit
