Reptile New Patient Form

In order to more efficiently serve you and your pet, we ask that you take a few moments to fill out this questionnaire about your reptile. This will enable the doctor to focus on particular areas of concern during the examination.

What is the species of the reptile being seen toda: Example: Snake
What was the origin of the reptile?: Private Breeder, Pet Store, etc
Was it captive bred or wild caught?: Captive bred or Wild Caught
If wild caught, how long has it been in captivity?: Example: 2 Years
How long have you owned this reptile?: Example: 2 Years
What type of enclosure is the pet housed in?: Example: Glass
Specify type of bedding/substrate used: Example: Sand
Are there any branches or plants in enclosure: Yes or No
Method and frequency of cleaning: Explain method and frequency of cleaning
Where in the house is the enclosure located?: Example: Bedroom
What heat source(s) are you using?: Example: Lamp
Temperature of enclosure?: Example: 80 Degrees
What light source(s) are you using?: Example: Bulb
How long are they on each day?: Example: 12 hours
How is water offered to the reptile?: Example: Dish
If a water bowl, How large is it, how often is it: Example: Medium Size, Daily
What are you feeding the reptile?: Be Specific ( Types and Amounts of food )
How often is food offered?: Example: two times a day
How is it stored prior to feeding time?: Example: Refrigerated
Offering any supplements in addition to the food?: Yes Or No
If feeding live insects or redents, Where are they: Example: Johns Animal World
How frequently?: Example: Weekly
How are they being housed and fed?: Example: Caged, By hand
Any other animals kept in the enclosure?: Yes or No
Do you have any other reptiles in other enclosures: Yes or No
If so, Please list types and numbers of reptiles: Example: 2 Snakes 1 Lizard
For Lizards and Snakes, How often does it shed?: Example: Once every two months
When was the most recent shed?: Example: Last week
Any problems associated with abnormal shedding?: Yes or No
Has reptile been dewormed?: Yes or No
Has reptile ever had a fecal examination?: Yes or No
If so, Please state when and with what medications: State Date and Medications used
Have you had any health problems with this reptile: Yes or No
Health problems with other reptiles in your collec: Yes or No
If so, Describe nature of problem: Describe nature of problem and when it occurred, was it resolved?
Why have your brought in your reptile today?: Explain why we are seeing your reptile today.
Form Verification

* Bold items are required information for the form to be submitted.