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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
B
Home Phone
C
Work Phone
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
Nutriberries
Avi-Cakes
Nuts
Fruit
Vegetables
Table foods
Bread
Meat
Eggs
Dairy Products
Other
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
