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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: *

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

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

We're excited to meet you!

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? *

Name

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