Patient/Owner Name *

Date *

Phone *

Email *

What species is your pet? *

Avian
Reptile
Small mammal

AVIAN HISTORY FORM

Origin *

Captive bred
Wild caught
Import
Unknown

From where did you obtain this bird? *

Does this bird have a reproductive history? *

Yes
No

If yes, please give details *

When did your bird last molt? *

How often has your bird been molting? *

Is your bird vaccinated? *

Yes
No

If yes, please give details *

Does your bird get wing trimmed? *

Yes
No

If yes, please give details *

Do you have other birds or pets? *

Yes
No

If yes, please give details *

Have you or your bird had any contact with other birds in the last 30 days? *

Yes
No

If yes, please give details *

When was the last bird added to your collection? *

REASON FOR PRESENTATION TODAY

What is the primary complaint or what signs have you noticed? *

How long have these problems been present? *

What health problems has your bird had previously? *

Has your bird received any treatment in the last 30 days? *

Yes
No

If yes, please give details *

Have you noticed any change in your bird’s behavior? *

Yes
No

If yes, please give details *

Have any other animals or persons in the household had any illness in the last 30 days? *

DIET

How often do you feed your animal? *

Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume)

Brand and amount? *

Type and amount? *

If meat

Freshly killed
Frozen/thawed
Live prey

If other, please specify *

What water supply do you provide?

Tap water
Bottled water
Rain/river water

How is water provided?

Bowl
Dripper system
Spray

How often *

How often is the water changed? *

Do you use any water supplements?

Yes
No

If yes, please give details: *

Have you noticed any changes in feeding or drinking behavior

Yes
No

If yes, please give details: *

Have you noticed any changes in droppings (fecal material, urine and urates)?

Yes
No

If yes, please give details: *

CAGE ENVIRONMENT

Where is the cage located? *

Inside
Outside

Please give details: *

What is the cage made of? *

Cage size *

What kind of bedding is used? *

What decor and furnishings are present?

If other, please specify *

Are bathing/spraying facilities provided?

Yes
No

If yes, please give details *

How often is the cage cleaned? *

What cleaning/disinfectant agents are used? *

What percentage of time does your bird spend inside and outside of its cage? *

Inside
Outside

If inside, please describe *

If outside, please describe *

Is the animal supervised when out of the cage? *

Yes
No

If yes, please give details *

Does your bird have regular exposure to sunlight? *

Yes
No

Frequency and length of time *

Is your bird exposed to full spectrum (UVA and UVB) lighting? *

Yes
No

Brand *

What is your bird’s light/dark cycle? *

Does anyone in the household smoke? *

Yes
No

If yes, please give details *

Do you use any aerosolized products? *

Yes
No

If yes, please give details *

Have there been changes in the bird’s environment in the last 3 months? *

Yes
No

If yes, please give details *

SMALL MAMMAL HISTORY FORM

HOW IS YOUR PET DOING AT HOME? *

IS YOUR PET HERE FOR WELLNESS OR PROBLEM VISIT? *

WHERE DID YOU GET YOUR PET? *

HOW LONG HAVE YOU HAD YOUR PET? *

DO YOU HAVE ANY OTHER PETS IN THE HOUSE? *

DESCRIBE YOUR PET’S ACTIVITY LEVEL (active/athletic, normal, inactive, hyperactive)

DESCRIBE YOUR PET’S CAGE

WHAT TYPE OF BEDDING IS USED IN THE CAGE? *

HOW IS WATER PROVIDED? *

IS YOUR PET ALLOWED TO RUN AROUND THE HOUSE? *

IS YOUR PET HOUSED INDOORS OR OUTDOORS? *

IS YOUR PET HOUSED ALONE OR WITH OTHERS? *

IF WITH OTHERS, HOW MANY?

WHAT DO YOU FEED YOUR PET? *

HOW MUCH? *

DO YOU FEED HAY TO YOUR PET? *

IF SO, WHAT KIND?

DO YOU FEED AN ALFALFA BASED PELLET OR TIMOTHY BASED PELLET? *

DOES YOUR PET RECEIVE ANY VITAMINS, MEDICATIONS OR NUTRITIONAL SUPPLEMENTS? *

IS YOUR PET EATING AND DRINKING NORMALLY? *

DOES YOUR PET HAVE EXPOSURE TO TOXINS? (second hand smoke, pesticides,etc) *

IS DEFECATION/URINATION NORMAL? *

DOES YOUR PET USE A LITTER BOX? *

HAS YOUR PET BEEN TO A VETERINARIAN BEFORE? IF SO, WHERE?

DOES YOUR PET HAVE ANY PREVIOUS HEALTH PROBLEMS? IF SO, WHAT?

HAS YOUR PET HAD ANY PREVIOUS SURGERIES?

HAS YOUR PET EVER BEEN VACCINATED? IF SO WHAT VACCINE WAS GIVEN?

HAVE THERE BEEN ANY BEHAVIORAL OR TRAINING PROBLEMS

REPTILE HISTORY FORM

HOW IS YOUR PET DOING AT HOME *

IS YOUR PET HERE FOR WELLNESS OR PROBLEM VISIT? *

WHERE DID YOU GET YOUR PET? *

HOW LONG HAVE YOU HAD YOUR PET? *

DO YOU HAVE ANY OTHER PETS IN THE HOUSE? *

DESCRIBE YOUR PET’S ACTIVITY LEVEL (active/athletic, normal, inactive, hyperactive) *

DESCRIBE YOUR PET’S CAGE *

DO YOU HAVE A UVB/UVA LIGHT ON THE CAGE? *

IF YES, HOW MANY HOURS PER DAY IS IT ON?

HOW OFTEN DO YOU CHANGE THE BULB? *

DO YOU HAVE A HEAT SOURCE FOR THE CAGE? *

IF YES, WHAT TYPE OF HEAT IS PROVIDED (BULB, HEATING PAD, ETC.)

WHAT TYPE OF ENRICHMENT ITEMS ARE IN THE CAGE? *

WHAT TYPE OF BEDDING IS USED IN THE CAGE? *

HOW IS WATER PROVIDED? *

IS YOUR PET HOUSED ALONE OR WITH OTHERS? *

IF WITH OTHERS, HOW MANY? *

WHAT DO YOU FEED YOUR PET? *

HOW MUCH? *

DOES YOUR PET RECEIVE ANY VITAMINS, MEDICATIONS OR NUTRITIONAL SUPPLEMENTS? *

I hereby authorize the following:

I am the owner of the above Pet, or am acting as an agent for the owner, and accept full financial responsibility for any charges incurred during the pet's visit. I hereby authorize the veterinarian to examine, prescribe for, or treat the above listed pets. I am aware that other personnel may be required in order to assist the veterinarian. Emergency cases shall always receive top priority, which is why occasional appointment delay is possible. We reserve the right to refuse to accept a pet at check-in for any reason, including without limitation due to illness or behavior.

For your protection, and that of others, we do not allow clients to assist in the restraint of pets, any owner that attempts to restrain or handle their pet while on the premises will be doing so at their own risk. I understand that my pet’s photos may be used for educational or media purposes. All dogs must be on a leash and properly controlled while on the premises. All cats and exotic pets must be presented in an appropriate carrier or on a leash. If you feel your pet may have been exposed to a potentially contagious disease, please notify a CVCC staff member prior to the appointment.

We agree to provide the specific services ("Services") to your Pet for each visit as indicated on the estimate. We will exercise reasonable judgment in all circumstances as we provide the services. You agree to pay us for the Services we provide to your Pet during each visit at the rates set forth at the start of such visit (collectively the "Charges"). Prices are subject to change without notice and seasonal rates for boarding and grooming may apply. In the event you do not pay your bill in full at time of check-out, you agree that a fee of 1.5% per month (16% per annum, will be charged. All collection and attorney fees necessary to collect this debt will be the responsibility of the owner or authorized agent. A returned check fee of $25 will be charged to your account each time we attempt to deposit the check and it is returned as insufficient funds.

Additional charges may be incurred when a pet is very difficult, exhibits risky behavior (biting, snapping, and intolerance to services in general) or has "soiling" behavior. These behaviors increase the amount of time that it takes to provide services for your pet. You acknowledge that we may contact appropriate authorities in the event your pet bites another pet or any person.

While your Pet is in our care, he or she may come into contact with other Pets. Every effort will be made to ensure the safety of our guests by enforcing strict restrictions. You acknowledge and agree that in the unlikely event your Pet is injured by another Pet, you hereby release CVCC from any liability for such injury. If your Pet injures another Pet, you will be solely responsible for any injury to the other Pet(s) as well as your own Pet.

You acknowledge and agree that in the unlikely event your Pet becomes ill or injured, or if your Pet passes away while on the premises, we will attempt to notify you via the telephone numbers you provided. If we cannot reach you, we at our sole discretion, may engage the services of our veterinarian or the area emergency veterinarian (which could be an outside facility) and/or administer medicine or give other necessary attention to your Pet, and you hereby authorize us to provide any such service at your additional expense. You also waive the right to refuse medical treatment to make the pet comfortable or stabilize the pet while under our care and any such service will be provided at your additional expense. If at any time your pet is found to have fleas or ticks while on the premises, we will provide the appropriate flea or tick removal treatment, and you hereby authorize us to provide such service at your additional expense.

Pets under the care of the veterinarian must be discharged by close of business for the day, otherwise the pet will be boarded at the nightly rate until the next business day.

For Grooming Services:

You represent that to the best of your knowledge, your pet has not been exposed to Rabies, Distemper, Giardia, Bordetella, Intestinal Parasites or parvovirus within 30 days prior to beginning their stay with us. You acknowledge that the Pet is healthy and we have confirmation from a licensed veterinarian that the Pet has received all vaccinations required, has been examined by a Veterinarian in the last 6 months and receives monthly flea and heartworm prevention.

We will not be responsible for any accidental death of the pet(s) due to the nature of any pre-existing health condition. We also will not be held responsible for minor nicks resulting from the grooming of matted, neglected coats or for irritation caused by removing coat from pets possessing mild to severe skin allergy, nor will we be held responsible for stressful effects that grooming may have upon a pet. We, as ethical groomers, reserve the right to refuse to dematt a pet UNLESS we deem that the pet can tolerate the amount of de-matting and that it could be done humanely.

All Pets are required to be vaccinated; however, it is still possible for a Pet to become ill, even if vaccinated. You agree that we are not liable for any illness suffered by your Pet during or after its stay.

Do not bring items with your Pet that are valuable or irreplaceable, We are not responsible for loss or damage to any personal item or toy left with your Pet.

If the pet is not called for at the time of the scheduled pickup date, we have the right to contact appropriate authorities as we see fit (in most cases local animal control officers) within ten (10) days after this date. The owner will receive one (1) notification by registered mail during this period no further notice will be given prior to a decision being made.

By signing you are indicating that you are the responsible party as an adult over the age of 18.You agree that you have full and complete authority to make all decisions, including those related to the expenditure of funds, for or on behalf of you and your pet and that you have had the opportunity to discuss it with us your satisfaction, and you agree to its terms.

Signature *

Clear Signature

Name *

First

Last

Date *

EXOTIC/AVIAN HISTORY FORM

Avian History Form

AVIAN HISTORY FORM

REASON FOR PRESENTATION TODAY

DIET

CAGE ENVIRONMENT

SMALL MAMMAL HISTORY FORM

REPTILE HISTORY FORM

Simply the best for your pet.

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