New Patient (Current Client): Exotic

1

Enter Your Information So We Can Fetch Your Account* This field is required.PLEASE ENTER THE INFORMATION ASSOCIATED WITH THE ACCOUNT WE HAVE ON FILE.

First Name

Last Name

Phone Number

Email Address

2

Please Enter Your Pet's Information* This field is required.

Pet's Name

Pet's Age or Birthday

Species

Sex

Breed

Color

3

How long have you owned {ltstronggtpleaseEnter96[1]}?* This field is required.

4

When/where did you obtain {ltstronggtpleaseEnter96[1]}?* This field is required.

5

Was there more than one pet obtained?* This field is required.

YESNO

6

Was {ltstronggtpleaseEnter96[1]} quarantined?* This field is required.

YESNO

7

How long were they quarantined for?* This field is required.

8

Are there any other pets in the household?* This field is required.

YESNO

9

What type of pets?

10

Were these pets added to the household after {ltstronggtpleaseEnter96[1]}?* This field is required.

YESNO

11

Were your other pets quarantined?* This field is required.

YESNO

12

Has {ltstronggtpleaseEnter96[1]} had any previous testing, treatment, or vaccines?* This field is required.If so, please attach all previous medical records at the end of this form so that the veterinarian may review them.

YESNO

13

Is {ltstronggtpleaseEnter96[1]} displaying any symptoms of illness or having any medical problems?* This field is required.

YESNO

14

Please explain

15

What type of environment does {ltstronggtpleaseEnter96[1]} reside in?* This field is required.

Cage

Pen

Hutch

Aquarium

Other

16

Where does {ltstronggtpleaseEnter96[1]} spend most of their time?* This field is required.

Indoor

Outdoor

Both

17

What is your estimated percentage that {ltstronggtpleaseEnter96[1]} spends in each?

18

What is {ltstronggtpleaseEnter96[1]}'s enclosure size?* This field is required.

List in gallons if applicable.

19

What is the enclosure made of?* This field is required.

20

What is the substrate(s) in the enclosure?* This field is required.

21

How often is the substrate(s) changed?* This field is required.

22

Does {ltstronggtpleaseEnter96[1]} require temperature control, humidity control, or lighting?* This field is required.

YESNO

23

Temperatures and ranges?* This field is required.

24

Humidity and lighting?* This field is required.

25

UVB source and time spent under?* This field is required.

26

When was the bulb last replaced?* This field is required.

27

Does {ltstronggtpleaseEnter96[1]} have availability of hide boxes, breeding boxes, nesting material, or humidity boxes?* This field is required.

YESNO

28

Does {ltstronggtpleaseEnter96[1]} receive any enrichment?* This field is required.

YESNO

29

How often?

30

What is {ltstronggtpleaseEnter96[1]}'s exercise or activity routine?* This field is required.

31

Does {ltstronggtpleaseEnter96[1]} travel?* This field is required.

YESNO

32

To where? (Domestic and International)

33

Is {ltstronggtpleaseEnter96[1]} ever boarded?* This field is required.

YESNO

34

Where are they boarded?

35

Does {ltstronggtpleaseEnter96[1]} ever receive grooming or trimming services?* This field is required.

YESNO

36

Where do they receive these services?

37

When was the last time, and how often does {ltstronggtpleaseEnter96[1]} receive these services?

38

Does {ltstronggtpleaseEnter96[1]} shed or molt?* This field is required.

YESNO

39

When was the last time?

40

Were there any difficulties with the previous sheds or molts?* This field is required.

YESNO

41

Please Explain

42

Have you noticed any behavior or activity changes with {ltstronggtpleaseEnter96[1]}?* This field is required.

YESNO

43

Please Explain

44

Is {ltstronggtpleaseEnter96[1]} spayed or neutered?* This field is required.

YESNO

45

Has {ltstronggtpleaseEnter96[1]} ever bred?* This field is required.

YESNO

48

Have you observed any breeding behaviors from {ltstronggtpleaseEnter96[1]}?* This field is required.

YESNO

49

Is {ltstronggtpleaseEnter96[1]} an egg layer?* This field is required.

YESNO

50

Are these eggs consumed by humans?* This field is required.

YESNO

51

When were the last eggs laid?

52

Have you observed any change in the amount or frequency of {ltstronggtpleaseEnter96[1]}'s eliminations or droppings?* This field is required.

YESNO

53

Please Explain

54

Have you observed any change in the quality or consistency of {ltstronggtpleaseEnter96[1]}'s eliminations or droppings?* This field is required.

YESNO

55

Please Explain

56

Has {ltstronggtpleaseEnter96[1]} had abnormal discharge?* This field is required.

YESNO

57

Please Explain

58

Have you observed any blood in {ltstronggtpleaseEnter96[1]}'s eliminations or droppings?* This field is required.

YESNO

59

When

60

Authorization to Treat* This field is required.I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet. I assume all responsibility for all charges incurred in the care of this animal.

I have read and consent.

61

Photo Release* This field is required.If we happen to capture a photo that we think other pet lovers will enjoy just as much as you do, do we have your permission to share the image on our social media, website, and other forms of related media? We will never include sensitive or personal information.

YESNO

62

Payment* This field is required.Payment is due in full at the time of service. We accept cash, debit, all credit cards, and pet insurance. We also offer CareCredit or Scratch Pay financing to help make the highest quality care accessible to all our patients. We do not offer in-house payment plans.

I have read, understand, and accept responsibility for payment to be rendered in full at the time of service.

63

Want To Earn "Best Client Ever" Status?Upload any previous medical records and vaccine history you have! It helps our team know exactly what your pet needs and keeps appointments running on time. *Bonus points if we don't have to play detective to track them down.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

If you do not have any previous records, please select 'Next'.

64

Optional: Show Us That Cute Face!Feel free to upload your favorite photo of your pet so we can add it to their hospital chart. Not only does it help us quickly identify your pet, but let's be honest—we enjoy seeing their adorable face every time we open their account. This photo will only be used within your pet's medical record. Uploading a photo does not grant permission for Shady Brook Animal Hospital to use it on social media, marketing materials, or for any other purpose.

65

Date* This field is required.

Date

66

Signature* This field is required.