Exotic Patient History Form

Exotic Patient History Form

If you're bringing in an exotic species, please complete this form in advance to help our team tailor care for your pet.
Owner Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact Email
example@example.com
Date of Appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Owner Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Have you ever had any other animal patients here at Angel Animal Hospital?
Animal Name
Species/Type (e.g., parrot, iguana, ferret)
Age/DOB
Sex
How long have you owned this animal?
Where did you acquire your animal?
Describe your animal's living environment (e.g., cage, tank, free roaming)
Has your animal had any previous illnesses or medical problems?
If yes, please describe previous illnesses or medical problems
Is your animal currently on any medication?
If yes, please list current medications and dosages
Has your animal been vaccinated or dewormed?
What symptoms or concerns prompted this visit?
How long?
Is your pet vaccinated?
Does your pet molt/shed?
If so, when was the last shed?
What is the current diet?
How often do you feed your animal?
What brand?
Do you use any nutritional supplements?
What supplement? (Type & Brand)
What water supply do you use?
How often is water changed?
What type of housing is this pet in?
What temperature is the enclosure kept at?
What is the size of the enclosure?
What is it made of?
How often is cage cleaned?
Do they have exposure to sunlight?
Is your pet exposed to full spectrum lighting?
Does anyone in the household smoke?
Has there been any changes in pets environment in the past 3 months?
Please provide any additional comments or information.
Signature Box
Terms and Conditions
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