Exotics Clients

• Owner Name:

• Spouse/Alternate owner:

• Address:

• City/Town:

• Postal Code:

• E-mail:

• Home Phone:

• Work:

• Cell/Other:

• Preferred method of contact:#Home#CellE-mailTextMail

• Pets Name:

• MaleFemale

• SpayedNeuteredunaltered

• Species:

  Guinea PigRabbitOther

• Other:

• Breed:

• Birth Date or Approx. Age:

• Colour/Making:

• Age or Date first obtained:

• Previous Veterinarian/Clinic:

• Are you a new client?YesNo

• If yes, how did you hear about our facility?Phone BookFriend/FamilyDriving By

• Other - Please explain:

• Who may we thank for recommending us?

• Diet:

• What food (pellets)are you currently feeding (brand name) :

• Type of hay provided:

• Type of greens fed:

• How often?

• Does your pet receive any supplements?

• Present Complaints:

• ItchinessSoresLamenessChange in appetiteWeight gainWeight lossLethargyDiarrheaConstipation

• Other - please explain

• Onset was:Suddengradualn/a

• Date symptoms first noticed:

• General Health:

• I would described my pet as:NormalHyperactiveLethargic

• Water Intake:NormalDecreasedIncreased

• Appetite:NormalDecreasedIncreased

• Urination:NormalDecreasedIncreased

• Stools:NormalWateryHard/Dry

• Coughing/ Sneezing/ Breathing Difficulty?YesNo

• If yes, Please explain:

• Is your pet currently on any medications?YesNo

• If yes, what kind of medication(s)?

• Environment:

• Where does your pet sleep and spend most of his/her time?IndoorsOutdoorsMy pet is exclusively kept indoors.

• Describe your pet’s enclosure:

• How many pets are kept in the same enclosure?

• Are there any other pets in the household (not kept in same enclosure)?YesNo

• If yes, what type of pets?

• Does your pet have contact with wild life (wild rabbits…)?YesNo

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