New Patient Questionnaire - Avian

If your bird is a new patient at Carolina Veterinary Specialists please fill out our New Avian Patient Form using one of the options below.

Please note that appointments must be made by phone, so please call us us if you want to book an appointment.

Client's first name *

Client's last name *

Client's date of birth (primary client must be 18 or older) *

Primary email address *

Primary phone number *

Please indicate if this number is a cell phone, home, or work number. *

Cell phone Home phone Work phone

Is it okay to text you at this number or leave voice mail messages? *

Yes No

What is the best way to reach you? *

Call primary phone Text primary phone Email Call alternate phone Text alternate phone

Mailing address *

Additional client or authorized agent

Phone number for additional client or authorized agent

Is there anything you would like us to know about you or anyone else visiting with you, so that we can provide you with reasonable accommodations during your visit and make your visit with us as comfortable as possible? You can include things such as hearing or vision impairment, mobility impairment, language barriers, etc.

About Your Bird

Bird's name *

Date of hatch (or age) *

Species *

Color or mutation *

Sex *

Female Male Unknown

If your bird’s sex is known, how was it determined?

If your bird is female, has she ever laid eggs?

Date your bird was obtained *

Place your bird was obtained *

Enclosure

Please describe your bird's enclosure here. Please include the brand of cage(s), approximate dimensions, location in the home, contents of the enclosure and cage liner. *

Please describe any secondary enclosures or environments (eg. play stands, sleep cages), if provided.

If your bird is bathed, please describe how your bird is bathed and how often.

Does anyone in the home smoke or vape in the same room as your bird?

Yes No

Diet and Supplements

Please describe the diet you provide for your bird and what your bird actually eats. Include brand names for any commercially produced diets (eg. pellets, blended diets, and seed/nut mixes). Include details of fresh food items offered (eg. vegetables, fruits, and whole grains). Please state if the quantity of the food item is measured or if it is offered at all times. *

Please describe any supplements you provide for your bird here, including vitamins, mineral blocks, cuttlebones, etc.

Please describe the source of drinking water for your bird and if water is provided in a bottle or a bowl.

Environment and Enrichment

Are there any other BIRDS in your home? If so, please describe. Are these other birds healthy? *

Are there any other PETS in the home? If so, please describe. *

Is your bird exposed to any birds outside the home? If so, please describe. *

Behavior and Personality

Please describe your bird’s personality.

Are there any current or previous behavior concerns?

Medical History

Has your bird had previous preventative health care visits to a veterinarian? If so, please describe. *

Has your bird ever been seen in the past for a medical or behavioral problem by a veterinarian? If so, please describe. *

Previous medical records can be uploaded below or emailed to us at exotics@carolinavet.com. Will you be providing or requesting previous medical records for us? *

Yes No N/A

If "No," do we have permission to contact your previous veterinary hospital(s) to obtain medical records?

Yes No N/A

If "Yes," please provide the name(s) of previous veterinary hospital(s) we can contact to obtain medical records

Reason for Visit

What is the reason for your visit? *

Initial wellness exam Referral from another veterinarian Medical concern (non-referral) Behavioral concern (non-referral) Same-day emergency (non-referral)

If here for a medical or behavioral concern, please describe. Please include when the problem was first noticed, how it has changed, treatments used, and response to treatment.

If your bird is currently on any medications or complementary therapies, please provide details here, including any adverse drug reactions.

Other

Are there any special requests for handling your bird?

Please describe any additional questions or concerns you may have regarding your bird.

Upload Files or Images

You can upload document and image files here, including previous medical records, notes, radiographs (X-rays) and ultrasound images. We would love to see photos of your pet and where they live!

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