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Home » Reptile and Amphibian Intake Form – Reg

Reptile and Amphibian Intake Form – Reg

Patient Registration

Please schedule an appointment before filling out the New Patient Registration form below.

Owner's Name

First

Last

Address

Street Address

City

State / Province / Region

ZIP / Postal Code

Primary Phone(Required)

Email(Required)

Alternate Contact

Phone

Alternate Contact Email

Relationship

Pet Information

Pet's Name(Required)

Species(Required)

Sex(Required)

Male

Female

Unknown

Breed(Required)

Spayed or Neutered?(Required)

Yes

Unsure

Date of Birth/Approximate Age(Required)

Color(Required)

Other pets at home(Required)

Names of Previous Veterinarian and Emergency/Specialty Veterinary Clinics (If any)(Required)

Per Illinois law, does a court ordered ownership agreement apply to this animal?(Required)

Yes

Are you or your significant other active or retired military?(Required)

Yes

Where did you get your pet (pet store, breeder, previous owner, etc)(Required)

How long have you owned your pet?(Required)

Diet

What is your pet's main diet? Please include type, amount, and frequency. Include pellets/kibble, seed mix, vegetables, fruits, table food, treats, hay, vitamin and mineral supplements, etc.

Has your pet been eating and drinking normally? If not, please explain

Have there been any recent diet changes? If yes, when and what were the changes?

Environment

Type of cage and dimensions/gallons

Bulb Types

Floor type and substrate/bedding

Describe all of the items in the cage

Location of cage in your home

Temperature (please specify day and night if different, what temperature is the house kept at)

Does your pet spend time out of its cage? If yes, is it supervised? How long?

Are there other pets in the cage? If yes, please describe.

Reason for Visit

What physical symptoms have you noticed in your pet?

Couging

Sneezing

Vomiting

Diarrhea

Abnormal Breathing

Lethargy / Weakness

Increased Shedding / Loss of Hair / Color Change

Itchiness

Decreased Activity

Decreased Appetite

Weight Loss

Weight Gain

Masses or Lumps

Nasal Discharge

Eye Discharge

Other

Couging details

Sneezing details

Vomiting details

Diarrhea details

Abnormal Breathing details

Lethargy / Weakness details

Increased Shedding / Loss of Hair / Color Change details

Itchiness details

Decreased Activity details

Decreased Appetite details

Weight Loss details

Weight Gain details

Masses or Lumps details

Nasal Discharge details

Eye Discharge details

Other details

Color, Consistency, and Frequency of Feces

Please list any past and current medications

I hereby state that the information is true and correct to the best of my knowledge. I further agree that if I am not the owner or responsible party that I may still be held responsible to provide payment for any services that I order or authorize.

Owner Signature(Required)

Date(Required)

MM slash DD slash YYYY

We like to thank our clients who refer friends and family to us. How did you hear about our hospital?(Required)

(Internet, drive by, name of friend or family member, etc)