Owner first name *

Owner last name *

Owner date of birth *

Secondary owner or authorized agent

Email *

Primary phone number *

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

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

What is the best way to reach you? *

Address *

City *

State *

Zip code *

Occupation *

Place of employment *

About Your Exotic Companion Mammal

Pet's name *

Species *

Breed and color pattern (if known)

Date pet was obtained

Date of birth

Sex (gender) *

Place pet was obtained. Please state the name of the pet store, breeder, or rehoming organization (if known). *

Enclosure

Please describe your pet’s housing here. Please include materials and approximate dimensions of the cage and any provided exercise pens, location of your pet’s enclosure in the home, cage liners, wheels, dust baths, and litter boxes and litter used. *

Is your pet allowed to roam free in the home or taken outdoors? If so, please describe.

Diet and Supplements

Please describe how you offer drinking water to your pet. Please indicate if provided in a bowl or a bottle. *

Please describe the diet for your pet here. Please include brand names for any commercially produced diets. Please describe the amount offered of each food item if the quantity of the food item is measured or otherwise limited, or state if it is offered at all times. *

Please describe any supplements you provide for your pet here, including vitamins, mineral blocks, and others.

Environment and Enrichment

Are there any cage mates? If so, please describe. Are the cage mates healthy? *

Are there other pets in the home? If yes, please describe. *

If you provide enrichment items and activities for your pet, please describe here.

Behavior and Personality

Please describe your pet’s personality.

Have there been any previous behavioral concerns? If so, please describe.

Medical History

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

Ferrets only – Please provide the date of the last rabies vaccination and canine distemper vaccination (if known).

Ferrets only – Is your ferret currently on heartworm preventative? If so, please describe.

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

Reason for Visit

What is the reason for your visit? *

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 pet is currently on any medications or supplemental therapies, please provide details here, including any adverse drug reactions.

Other

Are there any special requests for handling your pet today?

Please describe any additional questions or concerns you may have about your pet.

Upload Files or Images

You can upload document and image files here, including previous medical records, notes, radiographs (X-rays) and ultrasound images, and photos of your pet or its enclosure or food.

Upload File

Browse...

Upload File

Browse...

Upload File

Browse...

Upload File

Browse...

Upload File

Browse...

Upload File

Browse...

Payment & Insurance

PAYMENT IN FULL IS EXPECTED AT THE TIME SERVICES ARE RENDERED. Prior to the treatment of your pet we will provide you with an itemized estimate. It is the policy of Carolina Veterinary Specialists to require a deposit on all hospitalized patients and those outpatients having extensive diagnostic or treatment procedures. Please ask our client care team if you have any questions.

Do you carry insurance? *

If yes, what is the name of your insurance company?

Referral Information

How did you hear about us? *

Veterinarian Referral (please provide details below)

Friend or family member

Internet

Community event

Signage

Printed publication

Radio

Other

If you have been referred to us by another veterinarian, please state the name of the veterinarian or animal hospital that referred you to us

Referring hospital name

Referring veterinarian name

Spam Blocker

New Patient Questionnaire - Exotic Mammals

About Your Exotic Companion Mammal

Enclosure

Diet and Supplements

Environment and Enrichment

Behavior and Personality

Medical History

Reason for Visit

Other

Upload Files or Images

Payment & Insurance

Referral Information

Caring for Pets in Huntersville