Reptile History Form
Please fill out this form completely prior to your appointment. As reptiles require very specific environmental conditions, their enclosure is extremely important. If they 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
*
Species
*
Lizard
Snake
Turtle
Tortoise
Other
Breed
*
Age or Date of Birth
*
Gender
*
Female
Male
Unknown
How long have you owned this pet?
*
Is this a new patient for our hosptial?
*
Yes
No
What is the reason for this patient's visit?
*
Please describe your pet's enclosure, including size, substrate, and ventilation.
*
How often is the enclosure cleaned?
*
If aquatic, how often do total water changes occur?
Do you track the temperature in your pet's cage?
*
Yes
No
What is the low temperature and the high temperature?
What is the basking temperature?
How do you provide heat?
*
Do you track the humidity in your pets's cage?
*
Yes
No
What is the current reading?
How do you provide humidity/water?
*
Does your pet have a regulated light cycle?
*
Yes
No
At what time are the lights on and off?
Does your pet have a UVB light?
*
Yes
No
How old is the light?
What style is the light?
What does your pet's diet consist of?
What is the feeding schedule?
Please provide the brands of food (if any) and any supplements given and how often
How old is your current supply of food?
What type of enrichment do your provide your pet?
Do you have multiple reptiles in different cages?
*
Yes
No
Do you sanitize your hands between pets?
Yes
No
Do you sanitize any tools between pets?
Yes
No
Does your pet live in a group?
*
Yes
No
How many are present?
Are they all the same gender or mixed?
All Male
All Female
Mixed
Unknown
When did you acquire the latest group member?
If you have one, what is your quarantine protocol?
Where did you obtain your pets?
Does your group undergo any routine treatments?
Yes
No
Please list any treatments and the last time they were done.
Are multiple pets showing signs of illness today?
Yes
No
Do you have pets other than the ones discussed on this form?
*
Yes
No
Please list them and specify if they have contact with today's patient.
Submit
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