Owner first name *

Owner last name *

Owner date of birth *

Secondary Owner / Authorized Agent Name

Email *

Primary phone number *

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

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

Alternate phone number

What is the best way to reach you? *

Address *

City *

State *

Zip code *

Occupation *

Place of employment *

About Your Reptile

Pet's name *

Date of birth or age *

Species *

Breed or morph

Sex (Gender) *

Date pet was obtained

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

Enclosure

Please describe your reptile’s enclosure. Please include caging materials and approximate dimensions of your reptile’s primary enclosure. Please include details on cage substrate or liner, branches, hide boxes, and other furniture. *

Do you use thermometers to track the temperatures in your reptile’s enclosure? If so, for terrestrial reptiles, what are the following temperatures – Nighttime temperature, daytime cool side temperature, daytime warm side temperature, and basking temperature? For aquatic reptiles, what is the water temperature and basking temperature? *

Please describe the lighting in your reptile’s enclosure, including photoperiod (number of hours of light per day). Please also include details on ultraviolet B (UVB) lighting (if provided), including manufacturer of UVB bulb(s), distance to the reptile, and bulb changing frequency. *

For terrestrial reptiles, please describe the source of drinking water and bathing or misting frequency. Is the humidity in your reptile’s enclosure measured? If so, what is the relative humidity? For aquatic reptiles, please describe water filtration and temperature regulation. *

Diet and Supplements

Please describe the diet plan for your reptile here. Please include brand names for any commercially produced diets (eg. pellets). Please describe the amount offered and frequency of each food item and how much is eaten. Please indicate if invertebrate food items are dusted or gut-loaded. *

When was the last time your reptile was last fed? When did it last eat?” *

Please describe any supplements you provide for your reptile here, including vitamin and mineral dusts or sprays. *

Environment and Enrichment

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

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

Is your reptile taken outdoors? If so, please describe. *

Medical History

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

When did your reptile last shed, and was it a complete shed?

(Females only) – Any recent egg laying or nesting behavior? If yes, 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 reptile is currently on any medications or supplemental therapies, please provide details here, including any adverse drug reactions.

Are there any special requests for handling your reptile today?

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

Upload Files or Images

Please attach any previous medical records and files, or images of enclosure, home, food, droppings, pet, etc.

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Salmonella Advisory Warning

Most, if not all, reptiles carry salmonella bacteria in their intestinal tract and intermittently or continuously shed these bacteria in their feces. Salmonella bacteria usually do not cause any illness in reptiles, but can cause serious illnesses in people.

Salmonella bacteria are easily spread from reptiles to humans. Humans may become
infected when they place their hands on objects, including food items, that have been in contact with the stool of reptiles, in their mouths.

Please refer to the ARAV at
http://arav.org/salmonella-bacteria-reptiles/ or the CDC at https://www.cdc.gov/features/salmonellafrogturtle/index.html for further information.

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 pet 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 - Reptiles

About Your Reptile

Enclosure

Diet and Supplements

Environment and Enrichment

Medical History

Reason For Visit

Upload Files or Images

Salmonella Advisory Warning

Payment & Insurance

Referral Information

Caring for Pets in Huntersville