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info@heartlandveterinaryil.com
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Exotic Patient Form
Owner Information
Client Name
First
Last
Client Email
Client Phone Number
Patient Information
Patient Name
Species
Breed
Sex
Male
Female
Unknown
If known, how was it determined?
If known, how was it determined?
Is your pet spayed (female) or neutered (male)?
Spayed
Neutered
Origin of pet (wild caught, breeder, pet store):
Hand Raised
Yes
No
Unknwon
Length of Ownership
Age
Band Number/Microchip
Environment
Cage
Size of cage(s):
Where is the enclosure housed?
% of day confined to enclosure vs free roaming:
How often is the cage cleaned?
What is used to clean the cage?
What substrate/bedding is used in the enclosure?
Types of Perches (if applicable)
How often are perches rotated?
Enclosure Humidity (if applicable)
What is the relative humidity of the enclosure?
How is the humidity determined?
Enclosure Temperature (if applicable)
What is the temperature gradient of the enclosure?
Day:
Night:
How is the temperature measured?
What type of heat source is utilized?
Bathing Habits
Type of Light (check those that apply)
Natural
Fluorescent
UVB
Amount of exposure to each daily:
When was the UVB bulb last changed (if applicable):
Exposure to Light
How often is pet bathed?
What is used to bathe pet?
Other access/environments (Play perches, floor, tables, outside, vacation home, etc.)
Are you aware of any exposure your pet may have had to the following (Please check all that may apply)?
Teflon Cook Wear
Smokers
Strong Cleaning Agents
Aerosols
Other…
Enter other…
Enrichment (Please check all that apply and elaborate on following lines):
Foragers
Shreddable Toys
Puzzle Toys
Target Training
etc.
Elaborate
Diet
What food (including the brand) is the pet provided? Please list all foods offered. List percentages of each category, if possible (i.e. % commercial diet, % vegetables, % fruits, % prey items):
What does the pet actually eat? Please list all food items that pet eats
How are non-commercial food prepared (raw, cooked, etc.)
Access to Fresh Water
How frequently is water offered?
How frequently are water bowls cleaned?
If applicable, does pet have adequate space/water for soaking?
Exercise
Describe the amount and type of exercise your pet receives:
Medical History
When and where was your pet last seen, prior to today? (Please have records sent to Heartland Veterinary Hospital)
Has your pet had any vaccines? If yes, please list which vaccines, when vaccine was given, and how vaccine was obtained.
If your pet currently on any medications? If yes, please list medications, dosage, frequency, route, and where medication was prescribed.
For the Visit Today
What is the primary reason for your appointment today?
If applicable, how long has this been a concern?
If applicable, what treatment has your pet received for current medical concern(s)?
What other medical or behavior concerns do you have (related or otherwise)?
Anything else that you would like us to be aware of regarding your pet?
Other Pets in the Household
Species:
Age(s):
Amount of contact between other pets and above patient:
Any known diseases with any other pet(s) within the household:
I authorize Heartland Veterinary Hospital to take and share photos/videos of my pet(s) on social media, website, and other promotional materials. I understand that no personal information will be shared.
Signature:
I acknowledge that completing this form does NOT schedule an appointment. I understand that I need to
call
Heartland Veterinary Hospital or fill out the
appointment request form
to book an appointment.
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