Small Mammal Initial Consult History Form

Small Mammal Initial Consult History Form
Your Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
We ask for your date of birth to ensure we meet regulatory guidelines when providing medications for your pet. Thank you for your understanding and cooperation!
Your date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you already scheduled an initial consult with PETS Referral Center for this pet?*

YesNo
Reason(s) for scheduling an appointment:
Primary care Veterinary:
Enter N/A if you do not have one
Pets name*
Sex*
Approximate age*
What species is your pet? *
(i.e. guinea pig, chinchilla, etc.)
Does your pet have a microchip?*
Where did you acquire your pet?*
(i.e. pet store, breeder, etc.)
Date acquired?*
Do you have any other pets?*
If yes, please specify:
If your pet is a Rabbit, is he/she vaccinated for Rabbit Hemorrhagic Disease (RHDV2)? *
If yes, when was the most recent vaccine and what type (if known)?
Does your pet have outdoor access? *
Please describe what type of cage/environment your pet lives in:
What do you use on the bottom of the cage? *
How often is the cage/environment cleaned?*
Method/frequency of cleaning food and water dishes: *
Are there any toys your pet plays with?*
If yes, please describe:
Has your pets environment changed recently?*
(i.e. cage, toys, etc.)
If yes, please describe:
What is the typical temperature of the area your pet lives in?*
Has it been particularly hot or cold recently? *
What do you feed your pet?*
Do you give any supplements, if so, what type?
For guinea pigs, do you provide vitamin C?
If yes, what type?
What, if any, treats are offered? *
How often?
Any recent diet changed or new foods? *
How is water offered? *
(i.e. sipper, bottle, bowl)
Are you here for a wellness visit? *
Are you here for a vaccination?*
If no, what problem(s) are you concerned about?
How long have you noticed the problem(s)?
Has your pet received treatment for this problem(s) yet?
Has your pet been sick previously?*
Has your pet ever seen by any other Veterinarians?*
If yes, name of Veterinarian(s)
If yes, when and why?
Is your pet currently on any medication(s)?*
If yes, what medication(s) and what amount?
Any other concerns or questions you have today that have not been addressed above:
Should be Empty:

Small Mammal Initial Consult History Form

We ask for your date of birth to ensure we meet regulatory guidelines when providing medications for your pet. Thank you for your understanding and cooperation!