Avian History Form
Please fill out this form completely prior to your appointment. If your pets live in a group, the well-being and history of the rest of the group is important as well.
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Date of Appointment
*
-
Month
-
Day
Year
Date
Pet's Name
*
Age or Date of Birth
*
Gender
*
Female
Male
Unknown
Has she ever shown any reproductive activity?
Yes
No
Breed
*
Is this a new patient for our hospital?
*
Yes
No
What is the reason for your visit?
*
Do you own other pets?
*
Yes
No
Please list them and specify if they have had contact with today's patient.
*
Describe your bird's enclosure, including size, substrate and ventilation.
*
How often is the enclosure cleaned?
*
Does your bird have a regulated light cycle?
*
What is your bird's diet? Please include brand of food as well as any supplements.
*
What is the feeding schedule?
*
How old is your current supply of food?
*
What kind of enrichment is provided for your bird(s)?
*
Do you have multiple birds?
*
Yes
No
Do you sanitize your hands between birds?
Yes
No
Do you sanitize your tools between uses?
Yes
No
Are the cages in close proximity?
Yes
No
Does your bird live in a group?
*
Yes
No
If living in a group, are all birds the same gender or mixed?
All Male
All Female
Mixed
Unknown
When did you acquire your latest group member?
If you have a quarantine protocol, what is it?
Where did you obtain your pets?
Please list all group treatments your birds receive and when they were last given. (example: parasite control)
Are multiple pets showing signs of illness?
Yes
No
Submit
Should be Empty: