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Home
New Clients
What to Expect
Veterinary Resources
Payment Options
Online Forms
Our Hospital
Meet Our Doctors
Meet Our Technicians
Meet Our Office Staff
Blog
Careers
Services
Wellness Exams
Vaccinations
Spay & Neuter
Microchipping
Surgery
Dental Care
All Services
Shop Online
Contact Us
Make an Appointment
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Exotic Pet Form
Exotic Pet Form
Client Information
First name
(Required)
Last name
(Required)
Email address
(Required)
Phone number
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Patient Information
Pet's name
(Required)
What is the species?
(Required)
What color are they?
(Required)
How old are they?
(Required)
How long have you owned them?
(Required)
How did you obtain it?
(Required)
What is their sex?
(Required)
Male
Female
How was their sex determined?
(Required)
Are they actively breeders?
(Required)
Yes
No
Have they ever laid eggs/had young?
(Required)
Yes
No
Enclosure Information
What is your set up like?
(Required)
How large is the enclosure?
(Required)
What is the temperature range?
(Required)
How is the temperature measured?
(Required)
Do you keep a heat source on them?
(Required)
Do they have UVB exposure?
(Required)
What is the relative humidity?
(Required)
Are they on substrate?
(Required)
Please upload a picture of your pet's enclosure here:
Max. file size: 50 MB.
Do they share their enclosure with other animals?
(Required)
Yes
No
Please list the pet's who share the enclosure.
(Required)
Feeding Information
What does their diet consist of?
(Required)
How often do they eat?
(Required)
What is your feeding setup?
(Required)
Do you offer any vitamins/supplements?
(Required)
Miscellaneous Information
Are there other animals in the home?
(Required)
Yes
No
What is their normal temperament?
(Required)
Have they ever had any previous medical issues?
(Required)
Yes
No
Have they previously been on any medication(s)?
(Required)
Yes
No
Please list previous medication(s) name and dosage.
(Required)
Have they had any blood work done?
(Required)
Yes
No
Are they currently on any medications?
(Required)
Yes
No
Please list current medication(s) name and dosage.
(Required)
Have they had any fecal checks?
(Required)
Yes
No
Authorization
Signature
(Required)
Reset signature
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Date
(Required)
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.
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