Avian 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?

7

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

Male

Female

Unknown

8

How often is your bird handled?

Daily

Occasionally

Never

9

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

10

What type of cage or enclosure is your bird in and what is the approximate size?

11

What types of toys or enrichment is in the enclosure?

12

What type of food is your bird offered? (Pellets? Seed? Fruits? Vegetables?) Please list brand/kind and amounts.

13

Please list any supplements that are added to your bird's food, the brand name, how they are added, and how often.

14

Is your bird on any current medications? If yes, please list.

16

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