Reptile History Form
An accurate history of your pet and their environment is extremely important. We would appreciate your cooperation in providing us with the following information. Please check the appropriate boxes or use the spaces provided.
Owner's Name
*
First Name
Last Name
Owner's Phone Number:
*
-
Area Code
Phone Number
Owner's Email:
example@example.com
Today's Date
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/
Month
/
Day
Year
Date
PATIENT INFORMATION
Patient Name:
*
Species:
*
For example: Lizard, Snake, etc.
Breed:
*
Gender:
*
Male
Female
Unknown
If gender is known, how was it determined?
*
If the gender is unknown, please type "N/A".
Date of hatch or estimated age?
*
Wild caught or captive bred?
*
Date acquired?
*
Use an approximation if you do not know the exact date.
Source?
*
Example: Pet Store, Breeder, Exotic Show, etc.
When was the last shed?
*
Was the last shed normal?
*
Yes
No
If no, please describe:
*
If the shed was normal, please type "N/A".
Female Questions
If your pet is a female, answer the following questions additionally. If your pet is a male, you may skip to the 'ENCLOSURE' section.
Have you ever bred or do you plan to breed this bird?
Yes
No
Unsure
How many clutches/litters has your reptile produced?
When was the most recent clutch/litter?
Any reproduction problems with this animal or any problems with her offspring? If yes, please describe.
ENCLOSURE
Where is the pet's enclosure kept in the house?
*
Are any animals kept in the same cage?
*
Yes
No
If yes, what type(s)?
*
If no, please type "N/A".
Are there any other pets in the household?
*
Yes
No
If yes, what type(s)?
*
If no, please type "N/A".
How much time does your reptile spend outside of their enclosure?
*
Is your reptile supervised when it is out?
*
At all times
Sometimes
Never
My pet does not leave its enclosure
Is supplemental heating provided outside the cage?
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Yes
No
If yes, please describe how.
*
If no, please type "N/A".
Have you observed your reptile eat foreign objects (sticks, bedding, chew walls, etc.)?
*
Yes
No
If yes, please descibe.
*
If no, please type "N/A".
Does your reptile hibernate?
*
Yes
No
If yes, please describe duration, temperature, and any monitoring provided during hibernation:
*
If no, please type "N/A".
Cage:
Type and size:
*
What substrate is used on the bottom of the cage?
*
Please describe any hiding and climbing area, live plants, swimming tubs, etc. in the cage.
*
How often is the cage cleaned and what cleaning products are used?
*
Aquatic Species
Skip to "Lighting" section if not relevant
How often is the water changed?
What type of filtration system is used?
Do you use a dechlorinator or any other type of water treatment?
Lighting:
Do you provide your reptile with any artificial lighting?
*
Yes
No
If yes, please specify below:
UVB: Type/strength
Heat/Basking Bulb
Other (If other, please describe below)
If Other, please describe here:
Type/Strength:
When was the bulb last changed?
Does the light pass through plastic or glass before reaching the reptile?
Where is the bulb located?
(i.e near UV light, on top of cage, etc.)
Estimated hours per day your pet received artificial light?
*
Do you turn the lights off at night?
*
Yes
No
Do you ever take your reptile outside to receive natural sunlight?
*
Yes
No
Temperature:
Do you have a thermometer(s) in the cage?
*
Yes
No
Is there a thermostat?
*
Yes
No
What is the temperature in the warmest part of the cage?
*
What is the temperature in the coolest part of the cage?
*
Is the temperature decreased at night?
*
Yes
No
If yes, by how much?
What devices are used to maintain the temperature?
Hot Rock
Heat Pad
Warm Room
Heat Light
Ceremic Heater
Aquarium Heater
Other
If Other, please list.
Humidity:
Is the humidity of the cage measured?
*
Yes
No
Humidity Range:
*
Is the cage misted?
*
Yes
No
If yes, how often?
Please note any recent changes to your pet's environment:
*
Please type N/A if none.
Diet/Medications
For this reptile, please list the amount fed/given and at what frequency for the following:
Vegetables, fruits (including types):
*
If none, please type N/A
Insect, mealworms, etc.:
*
If none, please type N/A
If you feed insects, mealworms, etc: Are they gut loaded or dusted?
Yes
No
If they are gut loaded or dusted, please describe:
Rodents, chicks, etc. (include types and source):
*
If none, please type N/A
If you feed rodents, chicks, etc: How are they fed?
Live
Fresh Killed
Frozen/Thawed
Pellets, commercial diets, or canned food (include types):
*
If none, please type N/A
If you feed other, please describe:
*
If none, please type N/A
Please list any supplements used: Include types, frequency, and how given.
*
If none, please type N/A
How is water offered? (i.e dish, misting, drip system)
*
If none, please type N/A
Does your reptile eat anything other than its intended diet? (i.e cat's food, house plants)
*
If none, please type N/A
Please list and describe any recent additions or changes to the diet:
*
If none, please type N/A
We pledge to do our very best to care for your pet's health needs. In return we ask you to accept the responsibility for charges incurred in the treatment of your pet. Payment is required at the time services are rendered. We accept major credit cards, cash, checks, and CareCredit. We may also require deposits for certain services. By signing this form, you agree to pay for all charges incurred in the care of this pet.
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Signature Date:
*
/
Month
/
Day
Year
Date
Submit
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