New Client Form for Reptile

311 West Gray St, Suite A Houston, TX 77019 Phone: 832-701-0077 info@furandfeathervet.com www.furandfeathervet.com
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: Name

Work Phone: Phone Number
Significant Other/Co Owner: Name

Cell Phone: Phone Number

Email Address: Email
Emergency Contact:
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.:

Yes No
PET INFORMATION

Reptile Wellness Form
Pet's Name:
Date of Birth/Approximate Age:
Species:
Sex:

Female Male
Duration in owners care?:
Origin (captive bred, wild, import):
Source (breeder, pet shop):
When was the last shed?:
Was it normal?:
Enclosure Specification
Type (arboreal, terrestrial, aquatic):
Size:
Construction (materials, fittings):
Decor, furnishings:
Ventilation (mesh, grills):
Cleaning routine (products used):
Cage mates?:
Environment
Heating Equipment:
Daytime temperature gradient:
Nighttime temperature gradient:
Water temperature:
Lighting Equipment:
Humidity:
Diet
What percent of your reptile's diet consists of the following?
Please specify percent actually eaten, not percent offered:

FRUITS/VEGGIES
% Eaten: Types:

INSECTS/MEALWORMS ETC
% Eaten: Types:
Are they "gut loaded" or dusted before feeding to your reptile?

Yes No
Describe:
RODENTS/CHICKS ETC
% Eaten:    Source:     Types:
Are they fed:     Live   Killed   Both

PELLETS, COMMERCIAL DIET, CANNED FOOD
% Eaten:    Types:
Describe:
OTHER
% Eaten: Types:
How often do you feed your reptile?:
List any supplements, how they are given and how often:

Brand/Type: name   Dosage:

Brand/Type: name   Dosage:   frequency

Brand/Type: name   Dosage:   frequency
Does your reptile eat anything other than its intended diet?
Ex: the cat's food, houseplants.
How is water offered?
Ex: dish, misting, drip system
Please list any recent additions/changes in diet:
Reason for visit:
How is your pet doing?
Energy level:

Normal Increased Decreased
Current appetite:

Normal Increased Decreased
Drinking:

Normal Increased Decreased
Urination:

Normal Increased Decreased
Bowel Movements:

Normal Increased Decreased
Other:
Have you noticed any;

Vomiting Coughing Limping Sneezing Seizures Discharge from Eyes Discharge from Nose None
Please describe:
Skin Problems?

Sores/Scabs Redness Scaly Flaky Odor Itching Chewing Hair Loss Lumps/Bumps
Location:
Tell us about your pet's activities
How much time does your pet spend outdoors?

0% 25% 50% 75% 100%
If pet goes outside, where does it go?

Backyard Around Neighborhood Parks/Lakes/Ponds Spend Time in Country Other
What plant(s) does your pet have access to? This is important to know because some can be toxic to your pet.:
(Sago Palms, Palm trees, Lilies, Oleander, etc.)
Current or Previous Medical Conditions
Does your pet have any allergies/sensitivities to food, medication, vaccines, etc? If yes, please describe reaction:
Has your pet had any surgeries or anesthesia procedures?:
Did your pet have any problems/complications with anesthesia?
Medications
List all medications your pet is currently receiving:

Brand/Type: name   Dosage:

Brand/Type: name   Dosage:   frequency

Brand/Type: name   Dosage:   frequency

Brand/Type: name   Dosage:   frequency
Medical History
Name of Hospital/Clinic where records can be obtained?:

Hospital/Clinic: name * Phone: Phone Number*

Email: email

*Many hospitals/clinics require owner release of their pet's records
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.
Dear Fur & Feather Veterinary Hospital Clients:

We are asking that our clients please call in advance if unable to keep a previously scheduled appointment, including boarding reservations, grooming and drop-off appointments. Clients who need to schedule an appointment for their pets, especially a sick pet, appreciate the opportunity to utilize the available appointment time and obtain the care that their pet needs.

This letter notifies our clients that a $65.00 Missed Appointment Fee will be billed to the account if a courtesy cancellation call is not received 24 hours prior to the booked appointment time.

We thank you for trusting our team to provide the very best care for your beloved pets. We value you and our patients. If you have any questions, please feel free to ask to see me or just give me a call.

Sincerely,

Hospital Administrator

I have received a copy of this notice and I understand the above policy.
Client Name: First Name* Last Name*
Signature *

Clear
Date:

Month Day Year
Date
Should be Empty:

PET INFORMATION

Enclosure Specification

Environment

Diet

Tell us about your pet's activities

Current or Previous Medical Conditions

Medications

Medical History