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Please Note: We will be closed on Friday, July 4th in observance of Independence Day!

We have Rabbit Hemorrhagic Disease vaccines in stock!

History Form

This history form is for hamsters, rats, and mice.

Hamster, Rat, & Mouse 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 *

Patient Information

Pet's Name *

Species: *

Breed: *

Major Colors

Gender *

Male
Female
Unknown

Spayed/Neutered *

Yes
No
Unknown

Date of Birth/Age *

How long have you had this pet? *

Where did you get your pet? *

Pet Store
Breeder
Friend
Shelter
Other

If other, please specify. *

Environment

Describe your pet's enclosure - flooring, size, and materials. *

What bedding is used on the floor of the cage? *

Diet

Does your pet eat pellets or blocks? *

Yes
No

Does your pet eat a seed mix? *

Yes
No

What brand?

Does your pet eat fresh vegetables or fruit? *

Yes
No

Does your pet get any treats? *

Yes
No

If yes, what kinds? *

Previous Veterinary Care

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

Has your pet had previous medical problems? *

Is your pet sick? *

Yes
No

If your pet is sick, please describe the signs. *

Diarrhea
Overgrown Teeth
Scratching
Not Eating
Not Defecating
Head Tilt
Runny Nose
Eye Discharge
Lameness
Trouble Breathing
Other

If other, please describe. *

How long has your pet been showing these signs? *

Contact Us

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Call Us

Questions?

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



Contact

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

}

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? *

Custom Captcha *

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