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
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