Small Mammal Intake Form

1

Please fill this out prior to your visit.Please call or text us if you need to cancel 24 hours in advance to avoid a cancellation fee.

2

Your Name* This field is required.

First Name

Last Name

3

Phone Number* This field is required.

Area Code

Phone Number

4

Patient Name* This field is required.

5

Scheduled Appointment Date

Date

6

What is the species of animal?Ex: Hamster, Rabbit, Rat, Guinea Pig, Chinchilla, etc)

7

Is your animal male, female or is their sex unknown?

Male

Female

Unknown

8

Is your animal spayed or neutered?

YESNO

9

Does your pet have a reproductive history? If yes, please give details.

10

Please describe the type of cage or set up your animal is in.

11

What foods does your animal eat and in what amount?Please list the brand of pellets, brand of hay and any fruits and vegetables.

12

Please list any supplements added to your animal's food, the specific brand, how they are added, and how often they are given.

13

Are there any changes to their droppings (feces and urine)? If yes, please describe.

14

Is your pet currently on any medications? If yes, please list the medication, amount given and how often it is given.

16

Primary Reason For Visit/Concerns* This field is required.Please be as specific as possible (e.g. when issue started)