Poultry Initial Consult History Form

Poultry 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
Have you already scheduled an initial consult with PETS Referral Center for this pet?*

YesNo
Pets name**
Sex*
Approximate age *
What species is your bird?*
(i.e. Duck, chicken, pigeon, etc.)
If your pet is a chicken, what breed is he/she?
Does your bird have a microchip?*
Where did you acquire your bird?*
Date acquired? *
Do you have any other pets? *
If yes, please specify:
Where do you live (City and County)*
Have you noticed any of the following problems in this bird (check all that apply)*

Eye Discharge (both eyes)Eye swellingNasal dischargeTrouble breathingVoice changeBlue/purple/gray coloration of comb or faceAcute lethargyNone of the above
Are any other birds in the flock or house sick?*
Have any other birds in the flock or house died recently?*
Do you own any other species of birds that interact with this pet?*
If yes, please list:
Is your bird kept:*

IndoorsOutdoorsBoth
How many birds in your flock?*
Have there been any additions recently?*
Describe your birds coop or enclosure: *
What do you use as flooring?*
How often is the cage cleaned? *
Method/Frequency of cleaning food/water dishes:*
Are there any toys in your birds cage? *
If yes, please describe:
Has the birds environment changed recently?*
(cage, toys, etc.)
Is there any supplemental lighting or heating?*
If yes, please describe:
For female birds, when was the last time she laid an egg?
Was it normal?
Has your bird had any previous trouble laying eggs? *
For chickens, is there a rooster in the flock?
What foods are offered to your bird and what overall percentage? *
Of those food items, which is your birds favorite? *
Do you give your bird any supplements?*
If so, what type?
Any recent diet changes *
If yes, please describe:
How is water offered? *
i.e. sipper bottle, bowl, etc.
Are you here for a wellness visit? *
If no, what problem(s) are you concerned about?
How long have you noticed the problem(s)?
Has your bird received treatment for this problem(s) yet?
Has your bird been sick previously? *
Has your bird been seen by any other veterinarians? *
If yes, when and why?
Name of Veterinarian(s):
Is your bird currently on any medication(s)? *
If yes, which medication(s) and what amount?
Note any other concerns or questions you have today that have not been addressed above:
Should be Empty:

Poultry 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!