Reptile 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
Year
Month
Day
6
What is the species of animal?
7
Is your animal male, female or is their sex unknown?
Male
Female
Unknown
8
How large is your animals regular enclosure, and what is it made of? (Ex: Glass 20" long aquarium)
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9
Do you provide UVA or UVB bulbs? If yes, what style of bulbs? (Ex: fluorescent, mercury, vapor, linear)
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10
What are the daytime temperatures of the enclosure, at the cool end and at the warmest spot?
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11
How are the temperature and humidity levels monitored in the enclosure?
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12
What substrate is used in the enclosure? (Ex: EcoEarth, newspaper, reptile carpet, etc)
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13
Please list any supplements or vitamins that are added to your reptiles food, the brand name, how they are added, and how often. (Ex: Repashy Calcium Plus dusted onto crickets, twice a week)
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14
Is live prey offered to your reptile? If yes, what types of animal prey are offered? (Ex: live crickets, superworms) How often?
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15
What types of plant based foods are offered to your reptile? How much is given and how often? (Ex: Spring mix, kale and bell peppers offered daily. Blueberries offered once a week)
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16
Primary Reason For Visit/Concerns* This field is required.Please be as specific as possible (e.g. when issue started)
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Reptile Intake Form