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1 Taft Ct, Rockville, MD 20850
(240) 687-1414
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REQUEST PRESCRIPTION
PATIENT FORMS
AVIAN FORM
FISH QUESTIONNAIRE
REPTILE FORM
SMALL MAMMAL FORM
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BACK TO WEBSITE
REQUEST AN APPOINTMENT
REQUEST PRESCRIPTION
PATIENT FORMS
AVIAN FORM
FISH QUESTIONNAIRE
REPTILE FORM
SMALL MAMMAL FORM
REPTILE NEW PATIENT FORM
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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:
MM slash DD slash YYYY
How did you hear about us?
Name:
*
First
Last
Spouse/Secondary Name: (if applicable):
First
Last
Mailing Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
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California
Colorado
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Delaware
District of Columbia
Florida
Georgia
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Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
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Montana
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New York
North Carolina
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Northern Mariana Islands
Ohio
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
No
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
No
Unknown
Where are the thermometers located?
Do you use a full-spectrum (UVB) bulb?
Yes
No
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
No
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
No
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
No
What is the temperature set at?
How do you measure it?
Does the aquarium have a filter?
Yes
No
Do you dechlorinate the water?
Yes
No
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
No
How often do you add vitamins and supplements
What kind? (Include brand if known)
If insects are fed, are they gut-loaded?
Yes
No
Unknown
What do the insects eat?
MISELLANEOUS
Do you soak or bathe your reptile?
Yes
No
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
No
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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