New Client Form for Avian

New Client Form

Thank you for the opportunity to care for your beloved pet. Our goal is to treat your pet with the same love and quality care that we would with our own, and to provide the highest quality service. We take an integrative approach for the best health care with strong emphasis on nutrition as a base for excellent health. Please help us meet your needs and the needs of your pet by sharing the following important information:

Pet Owner's Name: First Name *   Last Name *

Address: Street Address
City   State   Zip

Home Phone:    Phone Number Cell Phone: Phone Number

Email Address:   Email *

Employer:      Work Phone: Phone Number

Significant Other or Co Owner:

Name: First Name    Last Name

Cell Phone: Phone Number

Email Address: Email

Emergency Contact:

Name: First Name Last Name

Cell Phone: Phone Number

How did you hear about us?:*

Or referred by (We would like to thank them):

May we take photographs of your pet(s) for educational purposes or for our social media? We will not release personal information such as your name :

YesNo

Pet's Name:

Date of Birth/Approximate Age:

Species:*

Color/Markings:

Sex:

FemaleMaleUnsure

Duration in owner's care?:

Origin (captive bred, wild import):

Source (Breeder, Pet Shop, etc):

What type of cage / enclosure does your bird have (approximate size)? :

Where in the house is the cage located?:

Does your pet spend time outside the cage?:

YesNo

If Yes, How much? / Where?:

Are other birds sharing the cage? Or in direct contact?:

How often is the enclosure cleaned, and what products are used?:

What kind of food do you feed your bird?
Please specify types/brands, how often, and percent of daily diet (0%-100%).

Pellets: type    How often: frequency % of Diet:%

Seed Mix: type  How often: frequency  % of Diet:%

Fruits: type   How often: frequency % of Diet:%

Veggies: type   How often: frequency % of Diet:%

Treats: type   How often: frequency % of Diet:%

Other: type   How often: frequency % of Diet:%

Do you give your bird supplements?
Kind and frequency:

Supplement: type    How often: amount

Supplement: name   How often: amount

Supplement: name   How often: amount

Please list any previous medical problems:

Has your bird ever been tested for:

PsittacosisPolyomavirusPsittacine Beak and Feather Disease

Has your bird been recently exposed to other birds? (new bird, boarding, etc):

YesNo

Is your bird groomed regularly?:

WingsBeakNailsNone

Do you bathe your bird?:

NoSpray BottleBath/Shower

If so, how often?

Does your bird have a full spectrum (UVB) light?

YesNo

If so, what brand?

Have there been any changes in the bird's environment?

Does your bird have any behavior problems?

Have you noticed any of the following?
If so, please describe:

Decreased appetite / Increased appetite: type

Anorexia: explain

Weight gain / Weight loss: explain

Vomiting / Regurgitation: explain

Difficulty Breathing: explain

Tail Bobbing: explain

Lethargy: explain

Fluffed Feathers: explain

Diarrhea: explain

Feather Picking: explain

Nasal or Eye Discharge: explain

Are there any smokers in the house?

YesNo

Have there been any changes in your bird's droppings? Please Describe:

(number, color, consistency).

Name of Hospital/Clinic where records can be obtained?:

Hospital/Clinic: name* Phone: #*

Email: Email

*Many hospitals/clinics require owner release of their pet's records

Is your pet covered under any pet insurance?:

YesNo

Would you like information on Veterinary Pet Insurance?:

Is there anything else you would like to mention or have concerns about?:

We gladly provide a written Health Care Plan with associated professional fees. This will be important to you since ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. In cases of extensive medical or surgical procedures, when full payment may be difficult at discharge, we accept Visa, Mastercard, American Express, Discover, or Care Credit.

We are updating our Cancellation Policy

as follows:

As of May 1, 2024, all appointments with the Doctor will require a Scheduling Fee.

Scheduling Fees are non-refundable for cancellations made within 24hrs of the scheduled appointment time.

Cancellations made prior to the 24hr window may have a partial refund returned to the card used to make the payment (minus $14 Processing Fee).

***The full Scheduling Fee amount may be utilized as a Credit on Account for future services.

We appreciate your understanding as we strive to provide excellent service to our patients in need!

Optional:

I authorize a Card to be held on file for future transactions.

Client Name: First Name * Last Name *

Client Signature:*

Date:

Date

PET INFORMATION

Pet Insurance