New Patient Form - Birds

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.

New Avian Patient Form

Please provide us with the following information.

Your First Avian Appointment

·       Important:  If you are a new client to Carolina Veterinary Specialists, please also complete a new client registration form. 

Client first name *

Client last name *

Primary phone number *

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

Cell phone Home phone Work phone

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

Email *

About Your Bird

Bird's name *

Species of bird *

Sex (gender) *

Female Male Unknown

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

Date of hatch (if known)

Date bird was obtained

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

Enclosure

Please describe the cage or other enclosure(s) for your bird here. Please include the brand of cage(s) (if purchased), approximate dimensions, location in the home, cage liner, and amount of time your bird is allowed out of the cage.” *

Please describe the contents of your bird’s enclosure here. Please include details about the perches, toys, swings, and food and water bowls or bottles.” *

Is the enclosure covered at night? *

Yes No

Please describe any play stands, mobile perches, or other enclosures (eg. sleep cage, outdoor enclosure) if provided.

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

Diet and Supplements

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

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, and others.

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. *

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

Behavior and Personality

Please describe your bird’s personality.

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

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.

Date of last polyomavirus vaccine (if ever)

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

No Yes

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, and photos of your pet or its enclosure or food.

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