Mammal History Form

Please fill out this form completely before your appointment.

Date (mm/dd/yyyy) *

Client's name *

Pet's name *

What is the reason for the visit?

Preventative care ("check-up") - no health concerns
General Consultation (This type of exam is appropriate for a pet that is exhibiting minor signs of illness, but is not urgently ill)
Recheck

If you have health concerns, please explain what is happening to your pet *

If you don't have any health concerns type n/a.

When did the symptoms start? *

If you don't have any health concerns type n/a.

Any previous medical history that the doctor should be aware of? (Please forward previous records to contact@wildsidevet.com ) *

Is the pet taking any medication? If yes, which medication? Please write the concentration, volume and frequency of the medication *

Will you require refill on any medications during your visit? *

Please know that any refills have to be requested at least 3 business days prior to your visit.

If yes, which one?

Is the pet eating normally? *

If not, please explain:

Is the pet defecating normally? *

If not, please explain:

Is the pet urinating normally? *

If not, please explain:

Is the pet drinking normally? *

If not, please explain:

What is the pet's diet? *

The more detailed information the better!

Do you offer water in a bowl or in a bottle? *

How big is the cage/enclosure? *

What is the bedding/ substrate? *

Does the animal live alone or are there other animals in the cage? *

Are there other animals in the house, if yes, which species? *

Is the pet vaccinated? If yes, please write which vaccines he has received and when it was last given *

Any other information that you believe it is important for the doctor to know?

Avian and Exotic Animal Health Center — a full-service mobile veterinary practice dedicated exclusively to exotic pets.