New Patient Exotic Pet Form

New Patient Exotic Pet Form

IMPORTANT: Please make an appointment prior to completing New Patient forms. Call Blue Springs Animal Hospital & Pet Resort at 816-229-1544.
Contact Information

Please provide current and accurate contact information. Our doctors may need to call you for lab results or other important patient information. We send appointment confirmations and reminders by email and/or text message. We will not spam or share your email or cell phone.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Primary Phone *
Please enter a valid phone number.Format: (000) 000-0000.
Email*

Confirmation Emailexample@example.com
- NOTE: If you have more than one new patient who will be seen at your upcoming appointmet, please complete additional New Patient Exotic Pet Forms for each new exotic pet. Please complete our regular New Patient Form for new dogs or cats.
- Pet Name*
- ReptileBirdMammalOther
- What is the species of your pet reptile?*
  example: bearded dragon, iguana, ball python, box turtle
- What is the species of your pet bird?*
  example: parakeet, cockatiel, parrot, cockatoo, macaw
- What is the species of your pet mammal?*
  example: rabbit, guinea pig, hamster, ferret
- FemaleFemale SpayedMaleMale NeuteredUnknown
- Pet Birthday or Age*
- How long have you had your pet?*
- Where did you obtain your pet?*
- What is your primary concern for your pet today?*
- How long has this been a problem?*
- Describe any previous medical conditions or procedures.*
- YesNoUnknown
- YesNo
- Describe any previous diagnostic tests and the results if you know them.*
- List any previous medications or treatments and describe how your pet responded.*
- Is your pet currently on any medications? If yes, please list the medications and doses. *
- Have you noticed any behavioral/activity changes? If yes, please describe. *
- Is your pet eating and drinking normally? If not, please describe. *
- Is your pet urinating and defecating normally? If not, please describe. *
- Have you noticed vomiting, diarrhea, or changes in size or consistency of stools? If yes, please describe.*
- Have you noticed any respiratory signs such as coughing, sneezing, or breathing harder or faster than normal? If yes, please describe. *
- Any other abnormalities or concerns?*
- Have you noticed any skin or feather abnormalities? If yes, please describe. *
- What was the approximate date of your bird's last molt?*
- If your bird is a female, has she laid any eggs? If yes, approximately when were eggs last produced?
- Describe your pet's enclosure type, size, flooring and what kind of bedding is used (such as paper towels, newspaper, fleece). *
- Describe anything that is inside your pet's enclosure. Include a description of toys, decorations, and all perches (wood, plastic, sand, other?). *
- Describe how your pet's enclosure is cleaned. How often is it spot cleaned vs fully cleaned? What type of cleaner or disinfectant is used? *
- Does your pet spend time outside the enclosure? Does he/she spend time loose in the house or go outdoors? *
- Describe your pet's diet including the type, amount, and frequency of each food. List any pelleted feeds, seeds, chopped feeds, or fresh foods such as veggies or fruit. *
- Describe any treats that your pet receives. Include type and frequency. *
- What is your pet's water source (bowl vs bottle)? How frequently are the food and water containers cleaned? Is the water treated with anything?*
- Describe any supplements you give your pet. Include brand, dose, and frequency. *
- Have there been any recent changes to your pet's environment, diet, or supplements as described above? Please explain. *
- Have you noticed any skin abnormalities? If yes, please describe. *
- What was the approximate date of your pet's last shed?*
- Did your pet shed normally or abnormally? Please describe. *
- Has your pet had any egg production? If yes, approximately when were eggs last produced? *
- Describe your pet's enclosure including type, size, flooring, and what kind of bedding is used. *
- Describe what is inside your pet's enclosure. Include a description of toys, furniture, hiding places, humidity box, plants, etc. *
- Describe how your pet's enclosure is cleaned. How often is it spot cleaned vs fully cleaned? What type of cleaner or disinfectant is used? *
- Describe the temperature regulation of your pet's environment. Include thermometers (number + location + type) and temperature ranges ( low end? mid-range? high end/basking?)*
- Describe the humidity regulation of your pet's environment. Is a humidifier/misting/drip system present? Describe hygrometers (type + location) and humidity setting or range. *
- Describe the heating of your pet's environment. List heat sources (mats/bulbs), number, and location. *
- Describe the lighting in your pet's environment. List UV lights (UVA/UVB and strip/bulb). What is the day/night cycle and are there any light or heat sources at night?*
- Does your pet spend time outside the enclosure? Does he/she spend time loose in the house or go outdoors? *
- Is your pet fed insects? Type? Source? Frequency & number? Are the insects gut loaded (fed nutrient rich foods 12-24 hours before feeding them to your pet)?*
- Is your pet fed salad, vegetables, and/or fruits? What types and how often?*
- Is your pet fed rodents or other whole prey? If yes, how often? Type and size? Live or frozen/thawed?*
- Is your pet fed a pelleted diet? If yes, describe the type/brand, amount, and frequency. *
- What is your pet's water source? How frequently is it changed? Is the water treated with anything?*
- Describe any supplements you give your pet. Calcium with or without Vitamin D? Multivitamin? List brand, dose, and frequency. *
- Have there been any recent changes to your pet's environment, diet, or supplements as described above? Please explain. *
- Have you noticed any skin abnormalities, itching, or scratching? If yes, please describe. *
- Describe your pet's enclosure type, size, flooring and what kind of bedding is used (such as paper towels, newspaper, shavings). *
- Describe anything that is in your pet's enclosure. Include a description of toys, hiding places, decorations, exercise equipment, etc.*
- Describe how your pet's enclosure is cleaned. How often is it spot cleaned vs fully cleaned? What type of cleaner or disinfectant is used? *
- Does your pet spend time outside the enclosure? Does he/she spend time loose in the house or go outdoors? *
- Describe your pet's diet including the type, amount, and frequency of each food. List any pelleted feeds, hay, greens, or fresh foods such as veggies or fruit. *
- Describe any treats that your pet receives including type and frequency. *
- What is your pet's water source (bowl vs bottle)? How frequently are the food and water containers cleaned? Is the water treated with anything?*
- Describe any supplements you give your pet. Include brand, dose, and frequency. If your pet is a guinea pig, does he/she have a source of Vitamin C? *
- Have there been any recent changes to your pet's environment, diet, or supplements as described above? Please explain. *
- If possible please upload or bring previous medical records including vaccine history (if applicable), lab work, and Xrays to your visit. Also bring any medications your pet is currently taking or has previously taken.
- Upload Records
  
  Cancelof
- Payment Policy
- Blue Springs Animal Hospital accepts
- Credit or Debit CardPersonal CheckCashOther
- YesNo
- Insurance Company
- YesNo
- Notes or Special Instructions
- Please verify that you are human*
Should be Empty:

New Patient Exotic Pet Form

Contact Information

Payment Policy