SMALL MAMMAL 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:

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

Color/Markings:

Where did you obtain your pet?

Environment

What type of cage does your pet have?

What are the dimensions? (HxWxL)

Where in the house is the cage located?

What kind of bedding do you use?

Does your pet use a litter box?

What kind of litter do you use?

How often are the cage and the litter box cleaned?

Briefly describe the cage accessories (bowls, house, toys)

Does your pet spend time out of the cage?

Yes

How is that time supervised? (If out of cage)

How much and where?

Are there any other animals sharing the cage or in direct contact?

Yes

If yes above, explain

Describe the living arrangements:

How often is your pet handled?

Diet

What kind of food and treats do you give your pets?

How often and how much food are you feeding your pet?

Do you give your pets any supplements? For guinea pigs, do they receive Vitamin C? (In what form?)

Chinchillas

How often does your pet get a dust bath?

What kind of dust (brand if known) do you use?

Medical History

Please list any previous medical problems:

Please describe the current problem and why you’ve brought your pet in for examination today

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Phone

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