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Pet's Name
Pet's Age
Species
Breed / Type
Wild caught or captive bred?
Sex
Female
Male
Unknown
Confirmed by
Endoscopy
DNA Sexing
Other
Background Information
Background Information
Where acquired?
Breeder
Pet Store
Rescue
Other Location
Length of time owned
Does your bird roam freely in the house?
Yes
No
Is your bird allowed outside?
Yes
No
Is your bird housed by itself? If no, please specify.
Are there any other pets? If yes, please specify.
How many hours does your bird get outside the cage?
Husbandry
Husbandry
Describe your enclosure, including size, type/material of cage, number of perches, toys, etc. PLEASE BRING PICTURES
How often is the cage cleaned?
What type of disinfectant is used?
If covered, for how many hours at night?
Is there a separate cage at night or is the cage covered at night?
Is there any bedding material? If yes, please specify.
Do you bathe/mist your bird? If yes, please specify.
Any recent changes in housing? If yes, please specify.
Diet
Diet
Please list the items included in the diet, brand and amount/frequency fed.
How is water offered?
Frequency changed?
Are there any treats/table scraps offered? If yes, please specify.
Are there any supplements used? If yes, please specify.
Have there been recent changes to diet? If yes, please specify.
Owner Information
Owner Information
Owner's Name
Secondary Owner?
Yes
No
Secondary Owner's Name
Secondary Phone
Phone Number
Email
Address
City
State
Zip
How Did You Hear About Us?
Internet
Yellow Pages
Sign
Ad
Pet Store
Personal Referral
Pet Show
Other
Vet History
Vet History
Previous Veterinarian
Previous Veterinary Clinic
Any allergies or pre-existing conditions?
Have you scheduled an appointment with us?
Yes
No
When is your appointment scheduled for?
Date of Most Recent Vet Visit
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