Reptile Medical History

This is my current contact information.My contact information has changed.Please see receptionist with any changes.

Please take a moment to tell us about your snake, lizard, turtle, tortoise, or crocodilian.

Date

Name of Pet

First NameLast Name

Owner last name

First NameLast Name

Species

Wild caught, captive born, or captive bred:

Place acquired/previous owner:

How long have you been keeping this individual:

Any recent contact with other reptiles, please give details?

When was the last new reptile added to your collection?

Date of last skin shed:

How often has shedding occurred?

Describe any reproductive history or egg-laying:

Purpose of visit today

If illness, describe signs, duration, and severity:

List any medications you are giving:

Describe any changes in droppings (urine, urates, or feces)

Describe any recent changes in behavior:

Have any other animals or people in the household been sick lately?

Describe any previous illness and treatment:

List previous veterinarian, if any:

Diet

What food items are offered:

What is eaten:

How often fed

Method of feeding (e.g., live, fresh killed, thawed,blended):

Ifdiet includes insects, are they fed and watered before being offered to thereptile?

Describe items provided as feed to the insects:

Any vitamin/mineral supplements including brand name:

Water

Dimensions of dish or tank (including depth):

How often is container filled?

How often is container cleaned?

Housing

Dimensions & building materials of cage:

Describe cage furnishings:

Type of bedding/substrate:

Frequency of cage cleaning:

Method of cleaning/products used:

Kept alone or with how many others:

What other species:

Temperature range: at basking site:__________ away from basking site:________nighttime:________

Describe thermometer(s) in use:

Describe heating equipment (ceramic heat emitter,under-tank heater, light bulb, aquarium heater, thermostat control, etc):

Humidity range:

Lighting: Type and brand name of lamp:

Hours of light per day:_________ Is the light on a timer?________ How old is the bulb?

Any access to natural sunlight?_______ If so, is it through glass or screen?

Handling

How often:

By whom:

STATEMENT OF FINANCIAL RESPONSIBILITY

I am aware that I am responsible for all charges related to medical services that my pet receives at Brook-Falls Veterinary Hospital & Exotic Care.. I understand that I will be asked to leave a deposit for medical services should my pet require a hospital stay. I understand that I must pay in full at the time medical services are completed. I have been advised that any charges revealed during post care audits will be invoiced in a timely manner and remain my financial responsibility.

Signature

Date

I give permission for Brook-Falls Veterinary Hospital & Exotic Care to use any images or photos of my family and my pet on social media or our website.

YesNo

Signature

Date

REPTILE MEDICAL HISTORY