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Parrot, Finch, & Avian History Form

This history form is for Parrots, Finches, doves, wild birds, and birds of prey

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Avian History Form

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

This form is for parrots, finches, doves, wild birds, and birds of prey. If your pet is a poultry or waterfowl (chickens, ducks, etc), please click here.

Owner's Name *

First

Last

Phone *

Email *

Date *

Bird's name *

Basic Information

What species of bird do you have? *

Major Colors

How long have you owned your bird? *

Where was your bird acquired? *

Pet Store
Breeder
Rescue
Friend/Family
Other

(Other) Please Specify: *

Bird’s age or date of birth: *

Do you know if it is male or female? *

Male
Female
Unknown

DNA sexed?

Yes
No

(Female) Has your bird laid eggs before? *

Yes
No

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

Housing

Is your bird kept in a cage or aviary? *

Yes - Cage
Yes - Aviary
Other
No

(Other) Please Describe: *

What bedding do you use? *

How often is it cleaned? *

What is the flooring on the bottom of the cage? *

ex. wire bottom cage, newspaper, etc.

What is the flooring on the bottom of the aviary? *

ex. wire bottom cage, newspaper, etc.

What material is the cage made of? *

Describe the bedding in the cage *

How often is the cage cleaned? *

Is your bird exposed to smoke, vape, air fresheners, incense, or scented candles? *

Yes
No

(Yes) Please Specify: *

Do you use teflon or other nonstick pans? *

Yes
No

Feeding

What food items are offered? What brand? *

What does your bird primarily eat? *

Do you use any nutritional supplements? If yes, please specify:

How often is the water changed? *

Does your bird take a bath, or get misted or showered? *

Yes
No

(Yes) What type of bathing, and how often? *

Does your bird receive at least 10 hours of undisturbed quiet and darkness each night? *

Yes
No

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? *

Is there anything else we can help you with today?

I would like diet information.
I would like husbandry information.
I have a different question.

What is your question? *

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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

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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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