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We have Rabbit Hemorrhagic Disease vaccines in stock!

Chicken & Duck History Form

This history form is for poultry and waterfowl.

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Poultry & Waterfowl History Form

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

This form is for poultry (chickens, turkeys, pheasants, quail, etc.) and waterfowl (ducks, geese, swans, etc.) If you have a parrot, finch, wildlife, or other species of bird, please fill out our avian history form 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 did you acquire your bird? *

feed store or pet shop
breeder
rescue
other

Please describe: *

Bird’s age or date of birth: *

Do you know if it is male or female? *

Male
Female
Unknown

Is your pet laying eggs? *

Yes
No
I don't know
not applicable

How many birds are in your flock? *

Does your flock have any contact with rats or wild birds? *

Yes
No
I'm not sure

Housing

My bird is a: *

poultry
waterfowl

Has your chicken been vaccinated against Marek's disease? *

Yes
No
I don't know
my pet isn't a chicken

What is your bird's main diet? *

What brand of food are they eating, if known?

Does your flock get other treats? If yes, please specify:

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

Is your flock confined to a coop, or does it free range in your yard? *

completely free range
coop at night, free range during the day
mostly in coop & run
supervised free range
only in coop & run

What type of bedding do you use on the floor of the coop? *

What type of bedding do you use on the floor of their house? *

What kind of surfaces is your bird standing on during the day? *

What type of water source does your bird have? *

How often is it cleaned? *

Previous Veterinary Care

Has your bird been to a veterinarian before? *

Please list the vet clinic(s) they have received care at:

Has your pet had previous medical problems? *

Today's Visit

Is your bird currently ill? *

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? *

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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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