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Animal & Bird Health Care Center
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Doctors
Dr. Kenneth Dazen
Dr. David S Kupersmith
Dr. Jennifer Cromwell
Dr Stefan Gallini
Dr. Mike Miller
Staff
Services
Wellness & Vaccine: Dog & Cat
Avian Health Care
Small Mammal
Reptile
Radiology
Surgery
Anesthesia
Microchipping
Dentistry
Laser Therapy
Online Store
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Forms
>
New Client Form
Avian History Form
Dog/Cat History Form
Ferret History Form
Reptile History Form
Small Mammal History Form
Boarding Form
Resources
Pictures
Our Pets
In Memory
New Page
Home
Doctors
Dr. Kenneth Dazen
Dr. David S Kupersmith
Dr. Jennifer Cromwell
Dr Stefan Gallini
Dr. Mike Miller
Staff
Services
Wellness & Vaccine: Dog & Cat
Avian Health Care
Small Mammal
Reptile
Radiology
Surgery
Anesthesia
Microchipping
Dentistry
Laser Therapy
Online Store
Forms & Links
Forms
>
New Client Form
Avian History Form
Dog/Cat History Form
Ferret History Form
Reptile History Form
Small Mammal History Form
Boarding Form
Resources
Pictures
Our Pets
In Memory
New Page
Reptile History Form
*
Indicates required field
Name
*
First
Last
Email
*
Pet's Name
*
This pet
*
Is a new patient
has been seen before
Species
*
Gender
*
Male
Female
Unknown
Date of Birth
*
How long have you had your reptile?
*
Where did you obtain your reptile?
*
Housing
What type of enclosure does your pet live in?
*
What are the dimensions" HxWxL
*
Do you use a Hygrometer?
*
Yes
No
What is the humidity range
*
How is the enclosure heated? Light, pad, rock?
*
Do you use a thermometer?
*
Yes
No
What is the temperature?
Basking Area
*
Daytime
*
Nighttime
*
Do you use a full spectrum (UVB emitting) bulb?
*
What kind of bulb: Fluorescent, Mercury...
*
How often is the bulb changed?
*
Does you pet get exposure to direct sunlight (not through a window)
*
What is the bedding (substrate)
*
Is there a hiding area? What kind?
*
Are there plants, branches or other climbing structures?
*
Do other reptiles share the cage?
*
If so, how long have they been together?
*
Does your reptile spend time outside of its enclosure?
*
Yes
No
If yes, where and how much time?
*
Diet
What do you feed your reptile?
*
Please fill in the percentage of the total diet in each category
that your pet actually eats
:
total should equal 100%
Leafy Greens
*
Other Veggies
*
Fruits
*
Insects
*
Small Rodents
*
Pellets
*
Other
*
Thank you for taking the time to fill out this form. Having this information will allow you to get more out of your time with the doctor.
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