EXOTIC New Client and New Patient

1

Please Enter Your Information* This field is required.

First Name

Last Name

Home Address

Phone Number

Email Address

2

Is there a secondary owner (co-owner) you would like added to your account?* This field is required.NOTE: Adding a secondary owner (co-owner) to your account grants this individual authorization to present your pet(s) for treatment, make medical decisions, access records, and authorize consent and financial responsibilities.

YESNO

3

Secondary/Co-Owner Information

First Name

Last Name

Phone Number

Email Address

Relation to you

4

Please Enter Your Pet's Information

Pet's Name

Pet's Age or Birthday

Species

Sex

Breed

Color

5

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

6

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

7

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

YESNO

8

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

YESNO

9

How long was your pet quarantined? Number *

10

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

YESNO

11

What type of pets?

12

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

YESNO

13

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

YESNO

14

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

15

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

YESNO

16

Please explain

18

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

Indoor

Outdoor

Both

19

What is your estimated percentage spent in each?
Indoor: Percent
Outdoor: Percent

20

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

List in gallons if applicable.

21

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

22

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

23

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

24

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

YESNO

25

Temperature: Enter text
Ranges:    Enter text
Humidity:    Enter text
Lighting: Enter text
UVB Source:    Enter text
Time Spent Under:     Enter text
When Was The Bulb Last Replaced?    Enter text

26

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

YESNO

27

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

YESNO

28

How often?

29

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

30

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

YESNO

31

To where? (Domestic and International)

32

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

YESNO

33

Where do you have {ltstronggtpleaseEnter96[1]} boarded?

34

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

YESNO

35

Where do they receive these services?

36

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

37

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

YESNO

38

When was the last time?

39

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

YESNO

40

Please Explain

41

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

YESNO

42

Please Explain

43

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

YESNO

44

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

YESNO

47

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

YESNO

48

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

YESNO

49

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

YESNO

50

When were the last eggs laid?

51

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

YESNO

52

Please Explain

53

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

YESNO

54

Please Explain

55

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

YESNO

56

Please Explain

57

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

YESNO

58

When did you first notice the blood?

59

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 agree.

60

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

61

Arrival* This field is required.For your protection and that of others, pets MUST be properly restrained by a leash or carrier upon arrival. If your pet requires special accommodations, please give us a call when you arrive so we can assist you and your pet.

I have read and understand.

62

Late Arrival* This field is required.To ensure we have adequate time for all scheduled appointments and procedures, Shady Brook Animal Hospital operates primarily by appointment. We kindly ask that clients arrive on time for their scheduled visits. Clients arriving more than 10 minutes late may be asked to reschedule their appointment so that we can remain on schedule and provide each patient with the time and attention they deserve.

I have read and understand.

63

Rescheduling/Cancellations* This field is required.We understand that unexpected situations arise and that appointments may occasionally need to be rescheduled or cancelled. As a courtesy, we do not charge cancellation or rescheduling fees. However, if appointments are frequently canceled or rescheduled, we may require a non-refundable deposit or ask that your pet be scheduled as a drop-off visit to help us best manage our schedule and accommodate all patients.

I have read and understand.

64

Urgent/Emergency Visits* This field is required.We do take emergencies; however, these services may be subject to a higher fee schedule. For your convenience, we offer limited same-day appointments for urgent care sick patients; they fill up fast, so we recommend calling first thing in the morning.

I have read and understand.

65

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 and understand.

66

Prescription Refills* This field is required.We are happy to fill your pet's prescriptions! Refill requests may be submitted by phone, text, email, or through our website. Please allow 24–48 hours for prescription requests to be reviewed, processed, and prepared for pickup. To avoid unnecessary trips, we kindly ask that you wait until our team has notified you that your prescription is ready before coming to the hospital. Please Note: Some prescriptions, including special-order medications, compounded medications, and controlled substances, may require additional processing time. If you choose to use an outside or online pharmacy, we are happy to provide a written prescription for you to pick up at the hospital. However, we do not authorize, call in, or process prescription requests received by phone or fax from online pharmacies. (Additional information regarding this policy will be covered in the 'Third Party Pharmacy Requests' section.

I have read and understand.

67

THIRD-PARTY PHARMACY PRESCRIPTIONS & MEDICATION REQUESTS POLICY

At Shady Brook Animal Hospital, we understand there are many reasons clients may choose to purchase medications or preventatives from online retailers or outside pharmacies. We fully support your ability to choose where you obtain your pet’s medications and are happy to accommodate those requests.

To help ensure the safety and quality of your pet’s medications, we strongly encourage purchasing products only from properly accredited and certified veterinary pharmacies. However, if you choose to use an outside pharmacy, we want to make the process as simple and transparent as possible.

Our Prescription Process
Clients who choose to fill prescriptions through an outside pharmacy may request a written prescription from Shady Brook Animal Hospital.

Please note:
- Written prescriptions must be picked up directly from our hospital.
- We do not call prescriptions into outside pharmacies.
- We are unable to email a copy of the written prescription.
- We do not approve or process prescription requests submitted directly by online pharmacies via phone, fax, or electronic request.

This process allows us to better serve our patients while maintaining safe and accurate prescribing practices.

Why We Use This Process
We implemented this policy for several important reasons:

Patient Care Comes First
- Our priority is caring for our patients and providing support to our clients. Managing large volumes of faxed and electronic refill requests from outside pharmacies can be time-consuming and may reduce the time available for patient care. In many cases, refill requests are generated automatically by online pharmacies rather than initiated directly by pet owners, which can create confusion and delays.
Improved Prescription Accuracy
- Providing a written prescription creates clear documentation and reduces the risk of communication errors that can occur when information is relayed over the phone or through third-party systems.

Ordering Directly Through Shady Brook Animal Hospital
We encourage clients to consider purchasing medications directly from our hospital or through our online pharmacy. Our online store is regularly evaluated and compared with the most popular online pharmacies to offer our clients similar (or the same) pricing on most prescriptions.

When ordering through our clinic or online store:

No written prescription is required.
Orders are integrated directly with your pet’s medical record.
The medication supply chain is fully secure.
Products are stored, handled, and packaged according to manufacturer standards.
You are guaranteed authentic, name-brand products in the correct dosage and packaging.
Most importantly, medications purchased directly through Shady Brook Animal Hospital or our online store are backed not only by the manufacturer but also by us—your pet’s healthcare team.

We appreciate your understanding and thank you for allowing us to partner with you in your pet’s care.

68

Third-Party Pharmacy Policy Acknowledgement* This field is required.I have read the third party pharmacy policy and understand that Shady Brook Animal Hospital will not approve prescription requests through third-party pharmacies such as Chewy, Costco, Amazon, etc. I understand that if I prefer to obtain my pet's medications via these platforms, I will need to pick up a written prescription from Shady Brook Animal Hospital and present it to the pharmacy of my choice.

I have read and understand.

69

Mutual Respect Policy

Unfortunately, policies such as this one have become necessary in today's world. While the vast majority of our clients are kind, respectful, and appreciative of our team, we believe it is important to clearly outline our expectations to ensure a safe, welcoming, and professional environment for everyone.

At Shady Brook Animal Hospital, we are committed to providing a safe, welcoming, and respectful environment for our patients, clients, and team members.

Our staff are expected to treat every client and patient with professionalism, courtesy, compassion, and respect. In return, we expect all clients and visitors to extend the same level of respect to our team.

If a client ever feels uncomfortable, disrespected, or has concerns regarding the conduct of a staff member or another individual on our premises, we encourage them to speak with the Hospital Manager as soon as they feel comfortable doing so. We take these concerns seriously and are committed to addressing them professionally and respectfully.

Shady Brook Animal Hospital maintains a zero-tolerance policy for abusive, threatening, harassing, or disruptive behavior.

This includes, but is not limited to:

Verbal abuse, insults, or personal attacks
Threats of any kind, whether verbal, written, or physical
Intimidating, aggressive, or hostile behavior
Profanity or offensive language directed toward staff members or any other persons on the premise
Discriminatory, harassing, or inappropriate remarks
Physical violence, attempted violence, or threatening gestures
Damage to hospital property
Any behavior that compromises the safety, well-being, or ability of our team to provide patient care

Clients who engage in such behavior may:

Be asked to leave the premises immediately
Be escorted off the premises
Have future services refused
Have their client-patient relationship with Shady Brook Animal Hospital terminated at the discretion of hospital management
Require involvement of appropriate authorities if necessary.

We appreciate your partnership in helping us maintain a positive environment where our team can focus on what matters most—providing exceptional care for your pets.

70

Mutual Respect Policy Acknowledgement* This field is required.I have reviewed and understand SBAH's Mutual Respect Policy and acknowledge that all individuals on the premises are expected to treat one another with courtesy, professionalism, and respect. I understand that Shady Brook Animal Hospital maintains a zero-tolerance policy for abusive, threatening, harassing, or disruptive behavior and that violations of this policy may result in the refusal or termination of services, termination of the client-patient relationship, removal from the premises, and, when deemed necessary, involvement of appropriate authorities. I also understand that if I ever feel disrespected, uncomfortable, or have concerns regarding the conduct of a staff member or another individual on the premises, I am encouraged to speak with the Hospital Manager as soon as I feel comfortable doing so.

I have reviewed, understand, and acknowledge.

71

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

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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.

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Date* This field is required.

Date

74

Signature* This field is required.