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Avian New Patient Form
Please enter your information
First Name
*
Last Name
*
Street Address
*
City
*
State
*
Zip Code
*
Mobile Phone
*
Home Phone
*
Work Phone
*
Email
*
Preferred contact method:
*
Preferred contact method:
A
Mobile Phone
Preferred contact method:
B
Home Phone
Preferred contact method:
C
Work Phone
Preferred contact method:
D
Email
Please enter your pets information here
Pet's Name
*
Species
*
Age/Hatch Date
*
Color
*
DNA Sexed?
*
If not DNA sexed- how was sex
confirmed?
*
Date acquired
*
Obtained from?
*
Obtained from?
A
Pet Store
B
Shelter
C
Breeder
D
Rescue Group
E
Other
Animal Origin
*
Animal Origin
A
Hand Raised
B
Wild Caught
C
Unknown
Do you have other
Animal/Exotics?
*
Do you have other Animal/Exotics?
A
Yes
B
No
Reason for visit
*
Diet: What does your pet eat?
Do you feed Pellets?
*
Do you feed Pellets?
A
Yes
B
No
What brand pellets?
Additional diet items (check all
that apply)
*
Additional diet items (check all that apply)
Seeds
Additional diet items (check all that apply)
Nutriberries
Additional diet items (check all that apply)
Avi-Cakes
Additional diet items (check all that apply)
Nuts
Additional diet items (check all that apply)
Fruit
Additional diet items (check all that apply)
Vegetables
Additional diet items (check all that apply)
Table foods
Additional diet items (check all that apply)
Bread
Additional diet items (check all that apply)
Meat
Additional diet items (check all that apply)
Eggs
Additional diet items (check all that apply)
Dairy Products
Additional diet items (check all that apply)
Other
Additional diet items (check all that apply)
None
How often do you feed your pet
*
How is water offered
*
Housing and Environment
Where is your bird kept?
*
Where is your bird kept?
A
Always caged
B
Caged at night/part of the day
C
In an Aviary
D
Free in house
Where is cage/hutch located
*
What type of cage? (name and size if known)
*
What type of substrate do you use
to line the cage?
*
Frequency of cage cleaning?
*
How often do you bathe/shower
your bird?
*
How many hours of sleep (darkness) does the bird
have each day?
*
Does your bird play with toys?
*
What are his/her favorite toys?
*
Does your bird get exposed to any
of the following?
*
Does your bird get exposed to any of the following?
A
Cigarette Smoke
B
Scented Candles
C
Cleaning Products
D
Deodorants
E
Other
Do you use non-stick
cookware?
*
Do you use non-stick cookware?
A
Yes
B
No
Medical History
Any previous illness? Yes or No? If yes, please explain
*
Previous lab work
*
Do you want labwork
performed today?
*
Do you want labwork performed today?
A
Yes
B
No
C
Other
Taking any vitamin supplements, herbals, or
medications(s)
*
Past Surgery(s)
*
Noticed any of the following?
Decreased Appetite
*
Decreased Appetite
A
Yes
B
No
Last time pet has eaten?
*
Change in personality?
*
Change in personality?
A
No Change
B
Aggression
C
Lethargy
D
Difficult breathing
E
Lameness
F
Other
Eye/nose discharge?
*
Eye/nose discharge?
A
Yes
B
No
If yes, when was discharge first
seen?
Feather Loss?
*
Feather Loss?
A
Yes
B
No
If yes, what location and when was it first seen?
Change in stools?
*
Change in stools?
A
Normal
B
Diarrhea
C
Decrease in stool out-put
D
Small stool
E
Other
Anything else helpful to know about your pet or
visit?
*
Submit
