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Home » Reptile and Amphibian Intake Form

Reptile and Amphibian Intake Form

Pet's Name(Required)

Phone Number(Required)

Demographics

Species(Required)

Sex(Required)

Male

Female

Unknown

Spayed or Neutered?(Required)

Yes

Unsure

Date of Birth/Approximate Age(Required)

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

Get in touch

(847) 548-2626

1203 N. IL Route 83,
Grayslake, IL 60030

Make an appointment

Make Appointment

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Monday

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Tuesday

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Wednesday

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Thursday

8:00am - 6:00pm

Friday

8:00am - 6:00pm

Saturday

8:00am - 1:00pm

Sunday

Closed

(847) 548-2626

1203 N. IL Route 83,
Grayslake, IL 60030

Make an Appointment

Home
Our Team
Office Tour
Services
Resources
Shop Online
Contact Us