Exotic Patient Medical History Form

Owner's Name

Name*

First Last

Phone Number*

Please specify if the phone number is*

Mobile
Landline

Additional Phone Number

Please specify if the phone number is

Mobile
Landline

Email*

Enter Email Confirm Email

Co-owner's Name & Contact #

Name

First Last

Phone Number

Please specify if the phone number is

Mobile
Landline

Additional Phone Number

Please specify if the phone number is

Mobile
Landline

Email

Enter Email Confirm Email

Address

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of people and pets in household*

Whom may we thank for the referral?

Pet Information

Pet's Name*

Age (specify if age is in days, weeks, months or years)*

Date of Birth (if known)*

Is your pet spayed or neutered?*

Sex*

Species*

Variety*

Color*

ID#/Band/Microchip

Previous Veterinary Practice (if any)*

If intact female, any litters or clutches?

Yes
No

Length of time in current household*

How was pet acquired?*

Known Allergies*

Housing/Diet

Does your pet have access to the entire house?*

Yes
No

Is your pet:*

Indoor
Outdoor
Both
Caged

Describe your pet’s enclosure (type/size/location/objects inside)*

Please include at least one picture of your pet's enclosure.*

This is to help us visualize how the space is allocated for the various activities that your pet may perform on a daily basis (e.g. hiding, basking, soaking, feeding, playing, etc.). If you utilize lights (UVB, heat lamps, and/or traditional lighting), under heat mats, misting systems, etc., it is helpful to see where those are located in terms of where your pet likes to spend the majority of their time. It also helps us to see how you are monitoring the temperature and humidity and how you are feeding. Knowing where the enclosure is within or outside of the house and where it is in relation to other pet enclosures that you may have, is also useful. Thank you for helping us provide the best care that we can for your pet!

Is your pet supervised when out of its enclosure?

Yes
No

What bedding/substrate is used?*

Temperature in enclosure (day and night)*

Humidity level*

Type of lighting used*

Is Lighting Timer Controlled?*

Yes
No

Do any other pets share enclosure?*

How often is the enclosure sanitized?*

What cleaning products are used for this?*

Diet (brand and type of pellet/seed)*

Type of hay (if any)

Percentage of daily feed: %Pellets: %Hay %Fresh produce

Other types of food offered / how often*

How long does it take for pet to eat each portion of food?*

How often is fresh water provided?*

Current medications or dietary supplements*

Reason for this Appointment*

Describe any medical problems, illnesses or injuries, please list date first noticed, changes observed during problem, and methods of treatment*

Pet Temperament*

Medical Records

Your pet's complete records must be received before scheduling an appointment Complete records means both vaccine information and medical chart. We will not offer shelter/rescue/AKC first free exam discounts unless the certificate is present at the first appointment.

File

Drop files here or

Share Your Pet's Picture!

We are able to add your pet's picture to their medical record. This is optional and is not required. Choose File

File

Helping your pets live longer, healthier and happier lives.

Get in Touch! (604) 277-8511

Owner's Name

Co-owner's Name & Contact #

Address

Pet Information

Housing/Diet

Medical Records

Share Your Pet's Picture!

Francis Petcare Hospital –
Formerly Catcare Veterinary Clinic

Address

Hours

Helping your pets live longer, healthier and happier lives.

Get in Touch! (604) 277-8511