REPTILE NEW PATIENT FORM - Maryland Exotics Veterinary Care

Environment and diet play a fundamental role in the health of exotic pets. In order to obtain the best assessment of your pet’s health and therefore provide the most appropriate care, it is very important that we have very detailed information regarding your pet. Please complete this form as thoroughly and accurately as possible. If you are unsure about any questions, please answer to the best of your ability or ask a veterinarian or staff member for clarification.

Client Information

Date:

How did you hear about us?

Name:*

First Last

Spouse/Secondary Name: (if applicable):

First Last

Mailing Address:*

Street Address Address Line 2 City State ZIP Code

Home Phone:

Work Phone:

Cell Phone:

Email Address:*

Patient Information

Pet’s name:*

Species:

Age/Date of birth:

Sex:

Male

Neutered Male

Female

Spayed Female

Unknown

Where did you obtain your reptile?

How long have you had your reptile?

Is your reptile:

Wild (caught)

Captive bred

Color/Markings

Housing

What type of enclosure does your reptile live in?

What are the dimensions? (HxWxL)

Do you use a hygrometer (humidity meter)?

Yes

Unknown

What is the humidity?

How is the enclosure heated? (e.g. light, heating pad, heat rock):

How long are the lights on/off during the day?

How long are the lights on/off during the night?

What is the temperature during the day?

What is the temperature during the night?

What is the temperature in the basking site?

Do you use thermometers?

Yes

Unknown

Where are the thermometers located?

Do you use a full-spectrum (UVB) bulb?

Yes

Unknown

What kind of bulb is it?

How often is it replaced and when was the last time?

Does your pet get direct sunlight? (not through a window)

Yes

Unknown

Does your reptile spend time outside of its enclosure? Explain:

What is the substrate? (bedding)

What is the water source?

Are there plants, branches, or other climbing structures?

Is there a hiding area? What kind?

Are there any other reptiles housed in the same enclosure?

Yes

What species and how long have they been together?

For aquatic species such as water turtles

How often do you change the water completely?

How often do you partially change the water?

Do you use a water heater?

Yes

What is the temperature set at?

How do you measure it?

Does the aquarium have a filter?

Yes

Do you dechlorinate the water?

Yes

Is there a basking site provided out of the water? (describe)

Diet

(Please fill in the percent of the total diet and types of food in each category that offer your pet and what your pet actually eats)

Leafy greens

Other vegetables

Legumes/Beans

Fruits

Insects/Small rodents:

Live

Dead

Select Live or Dead and Explain in the next field

Explain above choice of Insect/Small Rodent

Pellets- Brand/Type:

Other (including treats):

How often do you offer food?

Where do you feed your reptile?

Do you add vitamin or calcium supplements to the food?

Yes

How often do you add vitamins and supplements

What kind? (Include brand if known)

If insects are fed, are they gut-loaded?

Yes

Unknown

What do the insects eat?

MISELLANEOUS

Do you soak or bathe your reptile?

Yes

How often?

Do they have any seasonal behavior changes?

Medical History

Has your reptile ever been checked for intestinal parasites?

How often do they defecate?

Has your reptile ever laid eggs?

Yes

Unknown

How often does your reptile shed?

When was the last shed?

Were there problems?

Please tell us why you have brought your pet in for an examination:

Is there anything else you would like us to know today?

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