New Pet History Form – Exotics

Your Pet's Name:
Your First Name:
Your Last Name:
Phone:
Email:
How should we contact you?
Type of Pet:
Where did you get your pet?
How long have you owned your pet?
How often do you bathe your pet?
How often do you brush/comb your pet?
What type of exercise does your pet receive, and how often?
How much time does your pet spend outside?
Which wildlife is in your area? (Choose all that apply) *
rabbitssquirrelsskunksraccoonsdeernone
How often is your pet around other animals that are not your own? (which species)
Do you travel with your pet? If so, where has your pet traveled?
Does your pet go to: (Choose all that apply) *
GroomerBoardingPet ShowsPet StoresNone of the Above
Does anyone in your household smoke? *
YesNo
Is your pet on pet insurance
YesNo
Is Your pet Spayed or Neutered?
YesNo
If you chose NO for the previous question, do you plan to have it done?
YesNo
Do you plan to breed your pet?
YesNo
Does your pet have any known drug reactions?
YesNo
Do you have a UVB light for your pet?
YesNo
If yes to previous question, what type?
Do you have a thermometer in the cage/area?
YesNo
If yes to previous question, what are the readings?
Do you have a humidity monitor in the cage/area?
YesNo
If yes to previous question, what are the readings?
Is your pet on a preventative for controlling external parasites? (fleas and ticks) *
YesNo
Is your pet on a preventative for controlling internal parasites? (heartworm, roundworm, etc) *
YesNo
Has your pet been micro-chipped or tattooed? *
YesNo
Do you trim your pet's nails at home? *
YesNo
If no to the previous questions, would you like to learn?
YesNo
Check any of the following that are of concern to you regarding your pet's behavior/health
(Check all that apply)
Excessive NoiseLitterbox TrainingSoiling/Spraying insideProblems around childrenSheddingAnxietyJumpingStraying from homeItching/scratchingOverly rambunctiousBitingClawing or diggingBad breathDestructive BehaviorNone of the Above
Which of the following are services that you might utilize:
(Check all that apply)
Lodging/boarding facilityReferral rewards programWellness plansMassage therapyEvening hoursGroomingDay careProduct trialsNone of the Above
In an emergency where you can not be immediately contacted, you want Companions Animal Hospital to: *
Provide CPRDo not resuscitate

 
 
 


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