Gilbertsville Vet – Mammal Form

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We are pleased to welcome your new mammal to Gilbertsville Veterinary Hospital. Dr. John A. Coniglario treats and cares for a wide variety of exotic patients (read his bio on the Veterinarian’s page). Please fill out this form as completely as you can. If you have any questions please contact our office at (610) 367-4744 and we will be glad to help you. We look forward to working with you in maintaining your pet’s health.
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Date
First Name
Last Name
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Cell Phone
Home Phone
Email
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Pet Name
Species
Sex
Birthday or Estimated Age
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How was the sex of your pet determined?
DNA
Endoscopy
Visual
Other
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Origin
Captive bred
Wild caught import
Unknown
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How long have you had this pet?
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Where did you obtain this pet?
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Is your pet vaccinated?
Yes
No
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If yes, please list vaccinations and date received.
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If a primate, has your animal been tuberculosis (TB) tested?
Yes
No
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If yes, when?
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If applicable, do you have a license (DNR/USDA) to own this animal?
Yes
No
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Do you have other pets in the household?
Yes
No
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If yes, please list number and species.
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When was the last pet added to your family?
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Has your pet had contact with any other animals in the last 30 days?
Yes
No
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The next section will cover your pet's appointment and diet.
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What is the reason for your pet's visit?
Wellness
Illness
Second Opinion
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If visit is for an illness; What is the primary complaint or what signs have you noticed? How long have these problems been present?
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What health problems has your animal had previously, if any?
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Has any other animals or person in the household had any illness within the last 30 days?
Yes
No
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If yes, please give details.
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How often do you feed your pet?
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Indicate below which foods are eaten.
Hay
Pellets
Fruits/Vegetables
Treats
Other
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Please indicate brands and amounts for the types of food eaten.
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Do you use nutritional supplements?
Yes
No
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What type of water supply do you provide?
Tap Water
Bottled Water
River/Rain Water
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How is the water provided?
Bowl
Dripper
Spray
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How often is water given?
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How often is the water changed?
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Do you use water supplements?
Yes
No
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If yes, please explain.
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Have you noticed any changes in feeding or drinking behavior?
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Have you noticed any changes in droppings (fecal material, urine & urates) Please give details.
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The next section will cover cage environment.
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Please Select
Please Select
Yes
No
Does your pet have a cage?
Please Select
Please Select
Inside
Outside
Where is the cage located?
Cage Size?
What is the cage made of?
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Are bathing/spraying facilities provided?
Yes
No
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If yes, please explain.
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How often is the cage cleaned?
What disinfectants are used?
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What % of time does your animal spend inside of its cage?
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What % of time does your animal spend outside of its cage?
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Is your pet supervised when out of the cage?
Yes
No
Sometimes
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Have there been any changes in the environment in the last 3 months?
Yes
No
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What decor and furnishings are present?
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Is there ventilation (grills or mesh)?
Yes
No
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If yes, please explain.
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What type of bedding do you use?
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Is your animal litter trained?
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What is your pet's day and night cycle?
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Does anyone in the household smoke?
Yes
No
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Do you use aerosol products?
Yes
No
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Previous Veterinary Facility name (if applicable):
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Phone Number of Previous Veterinary Facility for us to call and request your pet's records (if applicable):
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I am the said owner or the agent for the above described pet and have the authority to execute this consent. I understand that I will be responsible for the cost of veterinary services, prescriptions, and product at the time they are rendered for my pet. I have read and understand this authorization and consent by typing my name below.
First Name
Last Name
Should be Empty: