Reptile New Client Form

Please complete the following form so we can get to know you and your pet better!

Owner's Name*

Spouse's Name

Address*

Home Phone #*

Work#

Cell#

Spouse Ph#

Work#

Email*

example@example.com

Driver's License #.

Employer

Spouses Employer

Pet's Name*

Breed*

Sex*

MaleFemaleUnknown

Color*

D.O.B/Age*

How long have you had your reptile*

Where was your pet obtained?*

What type of enclosure does your pet live in?*

Dimensions of enclosure*

Do you use a humidity meter?*

YesNo

How is the enclosure heated? *

Daytime Temperature *

Night Time Temperature*

Basking site?

Do you use a thermometer?*

YesNo

Where is thermometer located?*

If your reptile spends time outside of it's enclosure please explain *

What is your pets bedding arrangement?*

What is the water source?*

Are there any other reptiles in the same enclosure?*

YesNo

If so what species?

Do you soak or bathe your reptile?*

YesNo

Diet: Please fill in the percentage of the total diet and type of food in each category that your pet actually eats:

Leafy Greens - Enter % of Diet Below

Legumes/beans - Enter % of Diet Below

Fruits - Enter % of Diet Below

Other vegetables - Enter % of Diet Below

Pellets - Enter % of Diet Below

Insects/small Rodent - Enter % of Diet Below

How often do you offer food?*

Where do you feed your reptile?*

Do you add vitamins to the food?*

YesNo

Describe & How often

If insects are fed, are they gut loaded?*

YesNoUnknown

Medical History: Has your reptile ever been checked for intestinal parasites?*

YesNo

Has your reptile ever laid eggs?*

YesNoUnknown

How often does your reptile defecate?*

How often does your pet shed?*

When was last shed?*

Any problems while shedding?*

Any previous medical issues?*

Any other questions or concerns you would like to address?*

How did you hear about Northern Michigan Veterinary Hospital?*

Payment is required at time of service. Please select your preferred method of payment:*

CashCheckCredit Card

By signing I agree that the information I have provided is accurate. - am also assuming all responsibility for the fees incurred for the care and treatment of the above listed pet: Signature

Signature*

Date*

Date