Veterinary Intake Form

FRONT DESK: (408) 255-1739
forthebirds@sbcglobal.net

For the Birds Registration required for EVERY visit

Please fill out AFTER you have made an appointment.

Please ensure that you are available by phone at ALL times until your pet is released back into your care.

Have your phone ON and ringer on LOUD.
Owner Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Appointment Contact Phone Number*
Format: (000) 000-0000.
CellHome(Landline)WorkOther
Secondary Phone Number (If different from above)
Format: (000) 000-0000.
CellHome (Landline)WorkOther
Email*
example@example.com
Your Bird's Information*

NameBreed
AgeSex (Write Unknown If Not Sure)
How long have you had your bird?
Where did you get your bird?

Management Questionnaire*

Rows	Yes	No	Unknown	Other/Fill in Response
Does your bird eat Nutri-an Cakes from FTB?
Does your bird eat Harrison's Bird Food? Which one?
Does your bird eat fresh fruits/vegetables? If yes, please list.
Is your bird on a seed based diet? Which brand?
Does your bird get treats and nuts? What kind?
Does your bird chew paper/shred toys?
Does your bird explore small spaces/cavity seek?
Does your bird have a fuzzy tent?
Does your bird eat cooked/ table food? Describe if yes.
Does your bird fly freely in your home?
Do you use newspaper/paper towel bedding? If no, what do you use?
How often is the cage lining changed?
Do you change the water daily? List any additives.
Is your bird near a heater vent?
Is your bird exposed to unfiltered sunlight (UVB rays)?
Do you stroke/pet your bird's back?
Does your bird have cage-mates? How many and what species?
Has your bird been on any medications or supplements? Please list.
Has your bird been to another vet we can contact for records? Please list where if yes.
If you take your bird to another vet, can we share your records upon request?

Lack of AppetiteNo DroppingsExcess UrineDiarrheaVomitingOn Cage FloorLethargicBehavior IssuesHormonalLaying EggsRegurgitatingPickingPluckingLoss Of BalanceScratchingFluffed PostureLaceration/CutsBleedingTraumaChange of VoiceClickingLimpingCoughingOvergrown BeakNostril DischargeSneezingEye AbnormalitiesEye DischargeBreathing IssueWheezingPantingAnimal AttackedRegular/Annual ExamOther
YesNo
How long has this condition been going on for and with what frequency?
If this is an ongoing case/recheck, please list if you notice any improvement or changes with your bird.
Are there any other issues/concerns that you would like to discuss at your appointment?

Grooming requests (no additional charge)*

Rows	Yes	No
Nail Trim
Wing Trim

Vitamin ADECalcium GluconateBeak TrimLupronDeslorelin ImplantBand RemovalRecheck labwork DVM recommends
When is your appointment? Please do not submit this form unless you have scheduled an appointment*

MonthDayYear
Date
TO ALL CLIENTS: All appointments are drop offs due to exam room size. We are requiring all patients have an annual physical exam with gram stain, direct fecal, and bloodwork to remain in good active client standing (This price can range between $417.00-$463.20). This needs to be repeated 12 months after your bird's last exam with workup. We will contact you to discuss further diagnostics as needed.*

Yes I Authorize These Tests IF Annual is DueNo I Do Not Authorize, Cancel my appointment.
To full prepare for your appointment, many times the Doctor requests to see pictures of the birds cage/environment which can help aid us in ruling out potential problems in emergency/acute situations. Please take pictures of your birds cage and environment and have them ready. This includes any special toys they like to play with inside/outside the cage and/or any additional play structures they may use.

I understand
Authorization:

I am the owner of agent for the owner of the animals described, and I have the full and exclusive authority to execute this consent.

I authorize the doctor (& assistants the doctor may designate) to examine and administer treatment as theraputically &/or diagnostically necessary. Only in extreme emergencies will necessary treatment be given without your prior approval. In these emergency situations we will contact you as soon as possible.

I agree to pay for all services rendered, goods, and supplies when purchased

I understand that if my pet ever requires overnight hospitalization, there will not be overnight supervision provided and a deposit may be required for surgical or medical treatment.

I release this hospital form any and all liabilities.

By submitting this form I hereby acknowledge that I agree to all of the above.
Yes I AuthorizeNo I Do Not Authorize, Cancel my appointment.
Full payment is due at time of pickup. We take Visa or Mastercard.

Hospitalized birds require 50% deposit of the estimate given.

No payment plans are available.
After you drop off your bird will be visually assessed and placed in a queue to be seen by the doctor in appointment order. Life threatening emergencies will be triaged and prioritized accordingly. The doctor will call you to go over your birds case to determine your desired level of care and will provide you with a verbal estimate upon request. The doctor will then examine your bird and do any approved diagnostics or treatments. The doctor or receptionist will call you after the examination to go over findings and finalize your invoice.
WHY YOU MAY HAVE TO WAIT

We provide emergency services. Therefore, we see those cases which could be life or limb threatening first. We will try to see you in the order in which you arrive but patients with such a problem may be seen before you. If you feel your pet is seriously ill and cannot wait, tell us so we can re-evaluate your needs.

Thank you!
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