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We have Rabbit Hemorrhagic Disease vaccines in stock!

History Form

This history form is for birds.

Avian History Form

Please fill out the following form as thoroughly as possible. Please note: All * fields are required.

Owner's Name *

First

Last

Phone *

Email *

Date *

Bird's name *

Basic Information

What species of bird do you have? *

How long have you owned your bird? *

From where was your bird acquired? *

Bird’s age or date of birth: *

Do you know if it is male or female? *

Male
Female
Unknown

DNA sexed?

Yes
No

Do you have other pets? If yes, please list them.

Housing

Is your bird kept in a cage? *

Yes
No

What material is the cage made of? *

Describe the bedding in the cage *

How often is the cage cleaned? *

Are there smokers in your house? *

Yes
No

Feeding

What food items are offered? *

What does your bird primarily eat? *

Do you use any nutritional supplements? *

How often is the water changed? *

Previous Veterinary Care

Has your pet received veterinary care at another clinic? If so, please tell us the name of the clinic.

Has your pet had previous medical problems? *

Today's Visit

Is your bird currently ill? *

Yes
No

If yes, what are the symptoms? *

If yes, how long has it been sick? *

If yes, have you tried any treatments? *

Are any of your other pets also ill? *

Contact Us

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Questions?

Contact us with the information below or fill out our online form.

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Contact

E: info@exoticpetclinic.com
P: 831-440-8590

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Hours

Mon - Fri: 8:30 am to 6:00 pm
Sat - Sun: Closed



Location

5400 Scotts Valley Drive, Suite B
Scotts Valley, CA 95066

Name *

First

Last

Email *

Phone *

Phone Type *

Mobile
Landline

How can we help you? *

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