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We have Rabbit Hemorrhagic Disease vaccines in stock!

History Form

This history form is for rabbits, chinchillas, and guinea pigs.

Rabbit, Chinchilla, & Guinea Pig 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 *

How long have you had this pet? *

Where did you get this pet? *

Pet Store
Breeder
Friend
Shelter
Other

If other, please specify. *

Environment

Is your rabbit/guinea pig/chinchilla kept indoors or outdoors? *

Indoor
Outdoor

Describe the enclosure - flooring, size, and materials. *

What material is used to line the bottom of the cage? *

Does your pet use a litter box? *

Yes
No

If yes, what type of litter is used? *

Does your pet chew on carpet or other objects/materials when outside of the cage? *

Yes
No

If yes, what type of objects? *

Diet

Does your rabbit/guinea pig/chinchilla eat pellets? *

Yes
No

If yes, what type? *

Alfalfa
Timothy
Pellet mix with dried fruit
Unknown

What quantity of pellet do you offer daily? *

Free choice
Measured amount

Please describe (measured amount) *

Does your rabbit/guinea pig/chinchilla eat hay? *

Yes
No

If yes, what type? *

Alfalfa
Timothy
Other grass hay

How much hay is offered? *

Unlimited
Limited

If limited, please describe. *

Does your rabbit/guinea pig/chinchilla eat fresh vegetables daily? *

Yes
No

If yes, what kinds? *

Does your rabbit get any fruit or treats? *

Yes
No

If yes, what kinds? *

Previous Veterinary Care

Has your pet received care at another veterinary clinic? If so, please name 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
Drooling
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? *

Is there anything else you are interested in having done today?

Nail Trim
Flea Control
Rabbit Hemorrhagic Disease Vaccination
Grooming
I have a question about...

What's your question about? *

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

}

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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