General History

1

Pet Name* This field is required.

If they don't have a name, pick your favorite author, singer or artist!

2

Have we seen this pet at CBEAM recently?* This field is required.If it has been more than 3 months since your pet was seen, please select NO.

YES, within the last 3 months.NO, not recently.

3

Has their enclosure or set up changed since we saw them last?If you have not already provided a detailed description of your enclosure, please select "yes"

YESNO

4

How do you pronounce your pets' name? * This field is required.

5

Estimated Age* This field is required.Please include months or years

7

How was the gender determined?Blood test, visual, probe, etc.

9

Species / Breed

Guinea pig, golden horned unicorn, etc.

10

Please upload a photo of your petNot required

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

11

What prompted scheduling an exam?e.g. adopted a new pet, recently declined, received a reminder email, etc.

12

Clinical signs you are seeing

What is the problem you are bringing your pet in for?

When did it start? (leave blank for wellness visits)

13

What symptoms (if any) is your pet experiencing and how long has it been going on?* This field is required.

14

Has the issue improved, stayed the same, or declined as time has gone on?* This field is required.

Improved

Stayed the same

Declined

N/A

15

Does your pet have any chronic health issues?

16

What day is your pet's appointment?* This field is required.

Date

17

What type of appointment?* This field is required.

Emergency or urgent care

Wellness exam (No health concerns)

New Issue Exam

Progress and Follow up Visit

End of Life Services

Surgery or anesthetized procedure

18

Due to unpredictable nature of emergencies, the length of your pet’s stay with us cannot be anticipated and depends on the amount of critical emergencies we get in. Animals are triaged based on their specific needs. Your pet will be seen, stabilized, and given supportive care as soon as they arrive in the clinic. The wait time could be anywhere between 1-8 hours before your pet is ready for discharge. Please confirm you understand.* This field is required.

I understandI have additional questions

19

What additional questions do you have?

20

Please note, animals brought in for drop off services could potentially be with us for the entirety of their assigned doctor's shift, which can be about 10+ hours. We do our best to have pets ready and discharged before that, but cannot predict what emergencies will come in during their stay. If you do have a time restriction, please let us know ASAP so we can do our best to accomodate.

21

Pet Parent First and Last Name* This field is required.

First Name

Last Name

22

Email address* This field is required.

23

Best Contact for this visit:* This field is required.

Area Code

Phone Number

24

If your pet has been seen by another veterinarian since we last saw them, what is the clinic name and location?

25

Please describe your pet's carrier and any other belongings you are bringing with them.* This field is required.

Color

Size

Material

Other belongings (Blankets, bowls, toys)

Please confirm you understand we are not responsible for lost items if an accurate description is not provided.

26

How long have you had them?

27

How old was your pet when they were obtained?

28

Where was your pet obtained?Breeder, rescue, pet store, etc.

29

Coloring / Markings / Morph

Example: Pink with purple polka dots

30

Are they vaccinated against Mareks?for chicken patients only

Yes

No

I don't know

31

Does your pet lay eggs?

YESNO

32

How often does your pet lay eggs?

33

Have any of the eggs been an abnormal size, deformed or discolored?

34

When was their last shed, and was it normal?For reptile patients only

35

Does your pet socialize with other animals in your household, or have a cage mate?Please list the animals and duration of time spent together per day

36

Does your pet socialize with other animals outside of your household?Please list the animals and duration of time spent together per day

37

How much time does your pet spend unsupervised?

39

Enclosure description

40

Please upload a photo of the tank or enclosure

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

41

Please describe the hides available within the enclosure, and any cage furniture present

42

How often is the water changed?for aquatic pets only

43

What percentage of the water is changed each time?for aquatic pets only

44

How is the water changed? Siphoned or dumped out? for aquatic pets only

45

How often is the water tested?for aquatic pets only

46

What type of water test kit is used?for aquatic pets only

47

What type of filter do you have? for aquatic pets only

48

What is the water temperature? for aquatic pets only

49

What type of thermometer do you use?for aquatic pets only

50

Are there other fish in the tank? What kind and how many?for aquatic pets only

51

Is there any furniture or live plants?

52

What is the nighttime procedure for your pet?

Covered cage

Placed in nighttime cage

No change from day

53

What substrate is used / what is on the bottom of the enclosure?* This field is required.

54

How often do you clean their enclosure?

55

What do you clean their enclosure with?

56

Please describe any heat source (Including brand and wattage)

57

Do you have a thermostatic controller for your heat source?

YESNO

58

How close can your pet get to their heat source?

59

What are the temperatures in the enclosure?

Basking site

Daytime high

Daytime low

Nighttime high

Nighttime low

60

How is the temperature measured?

Are there multiple thermometers / locations? What types and where?

61

Do you have any humidity sources?

YESNO

62

Describe the humidity sources, their humidity level and how it is measured.

63

How often are they soaked, and for how long?for reptilian pets only

64

What light sources (both natural and artificial) are used and between what hours?

65

If a UV bulb or full spectrum bulb is present, what type of bulb is used?

Long fluorescent tube

Compact fluorescent (spiral)

Mercury Vapor

Metal Halide

Other

66

You selected "other." What type of bulb is used?

67

What is the brand and wattage of the bulb?

68

How old is the bulb and how often is it changed?

69

How close can your pet get to the light sources?

70

Is there any material (screen, glass, plexiglass, etc) between the light and your pet?

YESNO

71

Does your pet receive access to direct sunlight (not through glass or plastic)

YESNO

72

Current supplements and medicationsThis is to determine if your pet is still receiving prescribed medications, what they are and how often. Please include names, dosage and frequency information. If you do not have this information available to you, please list "as prescribed" and someone will follow up.

73

Do you need refills on any medications? Please list themPlease be specific so we can do our best to have these ready for you.

74

When did your pet last receive their medications?

75

When did your pet last eat?

76

Is your pet vaccinated?

YESNO

77

Please list the vaccination names and dates they were given

78

When was their last molt, and were there any problems noted with the molt?for avian and domestic fowl pets only

79

Do you trim your pet's wings?

YESNO

80

What technique of trimming do you prefer?

82

If you selected "other," how is water/hydration provided?

84

How often is the water changed?

85

Primary diet / frequency they are fed

86

If hay is offered, what type is it?

87

If pellets or a commercial diet is given, please give the brand/type, and if offered dry or soaked

88

Treats / frequency they are given

89

If vegetables are given, what types? Are they frozen, fresh, dehydrated, or in some other form?

90

If proteins are offered, list types of insects, fish, cheese, meat, etc. Are they live, frozen/thawed or dehydrated?

91

Do you gut load your insects?for reptilian pets only

YESNO

92

What are they loaded with? How long after loading are they fed to your reptile?for reptilian pets only

93

Does your pet always have access to food?

95

You selected "other." Please specify where your pet is fed.

96

How have your pet's eating or drinking habits changed?

97

Is your pet urinating normally? (If not, please describe)

98

Is your pet producing normal stool? (If not, please describe)

99

Please describe any changes to your pet's environment in the last month, including travel, new pets, change in diet, change in housing/bedding, or anything you think might be significant:

100

How many hours of undisturbed darkness does your pet have in each 24 hour period?

101

Do any smokers live in the house or visit regularly?

Yes

No

Rarely

Sometimes

102

Are any of the following present in your home? (Check all that apply)

Air fresheners

Insecticides

Cleaning Products with Fragrance

Candles

Teflon Cookware

Wood or oil burning heaters

House plants to which the pet has access

Painted or linoleum surfaces to which the pet has access

103

TREATMENT CONSENT:

By signing this document, I declare I am the lawful owner of all listed pets and all information is true and correct to the best of my knowledge. I hereby authorize the veterinarian(s) of The Center for Bird and Exotic Animal Medicine to examine, prescribe for or treat the my pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express verbal and/or written permission with the exception of another veterinary facility.

104

In order to refill medications through CBEAM a credit or debit card must be stored on file. The card will be charged for the price of the medications as soon as they are made. Medications that are not picked up within two weeks will be discarded without a refund.* This field is required.

I Understand

105

Signature Required

Clear