Reptile Medical History For our recordsThis is my current contact informationMy contact information has changed and I need to update my recordsPet's NameOwner Name First Last SpeciessnakelizardturtletortoisecrocodilianHow did you obtain your pet?Wild caughtcaptive borncaptive bredPlace acquired/previous ownerHow long have you been keeping this individualAny recent contact with other reptiles, please give details?When was the last new reptile added to your collection?Date of last skin shed: Date Format: MM slash DD slash YYYY How often has shedding occurred?Describe any reproductive history or egg-laying:Purpose of visit todayIf illness, describe signs, duration, and severity:List any medications you are giving:Describe any changes in droppings (urine, urates, or feces)Describe any recent changes in behavior:Have any other animals or people in the household been sick lately?Describe any previous illness and treatment:List previous veterinarian, if any:DietWhat food items are offered:What is eaten:How often fedMethod of feeding (e.g., live, fresh killed, thawed,blended):If diet includes insects, are they fed and watered before being offered to the reptile?Describe items provided as feed to the insects:Any vitamin/mineral supplements including brand name:WaterDimensions of dish or tank (including depth):How often is container filled?How often is container cleaned?HousingDimensions & building materials of cage:Describe cage furnishings:Type of bedding/substrate:Frequency of cage cleaning:Method of cleaning/products used:Kept alone or with how many others:What other species:Temperature range: at basking site:__________ away from basking site:________nighttime:________Describe thermometer(s) in use:Describe heating equipment (ceramic heat emitter,under-tank heater, light bulb, aquarium heater, thermostat control, etc):Humidity range:Lighting: Type and brand name of lamp:Hours of light per day:_________ Is the light on a timer?________ How old is the bulb?Any access to natural sunlight?_______ If so, is it through glass or screen?HandlingHow often:By whom:STATEMENT OF FINANCIAL RESPONSIBILITYI am aware that I am responsible for all charges related to medical services that my pet receives at Brook-Falls Veterinary Hospital & Exotic Care.. I understand that I will be asked to leave a deposit for medical services should my pet require a hospital stay. I understand that I must pay in full at the time medical services are completed. I have been advised that any charges revealed during post care audits will be invoiced in a timely manner and remain my financial responsibility.Name / Signature First Last Date Date Format: MM slash DD slash YYYY I give permission for Brook-Falls Veterinary Hospital & Exotic Care to use any images or photos of my family and my pet on social media or our website.YesNo
