Avian Initial Consult History Form

Avian 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*
How was your bird sexed?*

Blood testSurgicalUnsureN/A
Approximate age *
What species is your bird?*
(i.e. Amazon, cockatiel, finch, etc.)
Does your bird have a microchip?*
Where did you acquire your bird?*
Date acquired? *
Do you have any other pets? *
If yes, please specify:
Is your bird kept:*

IndoorsOutdoorsBoth
If your bird is caged, what type of cage do you have? *
What do you use at the bottom of the cage?*
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:
At night do you cover the bird*
How many hours or darkness does the bird have each day? *
How much time does your bird spend unsupervised out of the cage?*
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?
What treats are offered? *
How often?
Any recent diet changes *
If yes, please describe:
How is water offered? *
i.e. sipper bottle, bowl, etc.
Has your bird ever laid an egg?*
If yes, when was the last egg?
How frequent does she lay and how many eggs is typical?
Has your bird ever had trouble laying an egg or been treated for egg binding?*
Has your bird ever received a hormone implant (deslorelin) or injection (lupron)? *
Do you have a male and female housed together?*
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:

Avian 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!