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Reptile/Amphibian History Form
Date
*
Date Format: MM slash DD slash YYYY
Name
*
First
Last
Pet Name
*
Species
*
Age
*
Sex
*
Male
Female
Background Information
Length of time owned
*
Where Acquired
*
Breeder
Pet Store
Wild-caught/Captive Bred?
*
Deparasitized?
*
Yes
No
If yes, with what?
*
How often is animal handled?
*
Daily
Occasionally
Never
Animal Ever Taken Outside?
*
Yes
No
If yes, for how long?
*
When was last shed?
*
Any trouble shedding?
*
Yes
No
If yes, specify
*
Fecal consistency?
*
Last Bowel Movement
*
Husbandry
Enclosure Information
*
Type of enclosure, Size of enclosure, Cage Location, Cage Furniture, Cage Substrate
Frequency of cage cleaning?
*
Type of disinfectant used to clean cage?
*
Cage Environment:
Light cycle:
*
Type of lighting
*
Heat Source
*
Humidity Level
*
UVB Provided
*
Yes
No
UVB Last Changed
*
Strength of UVB bulb:
*
Temperature Minimum
*
Temperature Maximum
*
Basking
*
Nutrition
*
Type of Food, Amount fed/frequency, Water Source
When last fed?
*
Any other pets? If yes please specifiy
*
Any other reptiles? If yes please specifiy
*
Reptiles are housed together or singly?
*
If not housed together, where are other reptiles located?
*
Any new additions to the reptile population? If yes please specify
*
Aquatic Species ONLY:
Depth of water?
*
How much water is changed?
*
How often is the filter changed?
*
Strength of filter:
*
Is the water quality checked regularly?
*
Yes
No
When was the water quality last checked?
*
Past Medical History/Problems:
*
Current Presenting Problem:
*
Duration of Complaint
*
Δ
Home
New Clients
New Client Registration Form
Prescription Refill and Food Order Request Form
Reptile/Amphibian History Form
About Us
Services
Boarding Services
Boarding Form
Wellness and Preventive Exams
Vaccinations
Pet Health
Pet Health Library
Pet Insurance
How-To Videos
Pet Health Checker
Pet Food Recalls
Product Recalls
News
Contact Us
Make an Appointment
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