Exotic Mammal New Patient Form – Middle Creek Veterinary Hospital

Name or Identification of Pateint

Name of Owner

First Last

Common or scientific species name

Date of Birth and/or Approximate age

Sex

How long have you had this animal and from where did you obtain him?

Is your pet vaccinated? If yes, list vaccines and dates given

If applicable, do you have a license (DNR/USDA) to own this animal?

Yes
No

(Please bring your license with you as a photocopy will be required for the medical record.)

Do you have any other pets in your household? If yes, please list number and species

When was the last animal added to your household?

Has your pet had contact with any other animals in the last 30 days? If yes please provide details

Reason for presentation today

What is the primary complaint or what signs have you noticed? How long have these problems been present?

Has this animal had previous health problems? If yes please provide details

Has your pet received any medications in the last 3 months (i.e. heartworm medication, dewormer, flea treatments, etc.)? If yes please provide details

Have any other animals or persons in the household had any illness in the last 30 days? If yes please provide details

Cage Environment

What is the cage made of? What are the dimensions? Is there ventilation? (grills, or mesh) Please provide details

Where is the cage located?(inside, outside) Please provide details

What kind of bedding is used?

What decor and furnishings are present?

How often is the cage cleaned and what disinfectants/cleaning agents are used?

What precentage of time does your pet spend in the cage? Is your pet supervised when out of the cage? Please provide details

What is your pet's day and night cycle

Have there been changes in your pet’s environment in the last 3 months? If yes please provide details

Does anyone in the household smoke?

Yes
No

Do you use any aerosolized products?

Yes
No

Do you bathe your animal? If yes please provide details

Diet

How often do you feed your animal? Please indicate which foods are eaten and in what amounts

Do you use any nutritional supplements? If yes, what, and how much and how often

What water supply do you provide? (tap, bottled, rain) How is it provided? (bottle, dripper) How often? and How often is it changed?

Do you use any water supplements? If yes, what, and how much and how often

Have you noticed any changes in eating or drinking behavior? If yes, please give detail

Have you noticed any changes in droppings (fecal material, urine and urates)? If yes, please give detail

Any other comments or information:

Middle Creek Veterinary Hospital has a Facebook page and website that we use to educate clients and share interesting pet stories. May we have permission to use photos of your pet, their story and details of his/her medical history to help educate other clients in this way?

Yes
No

**Client’s names will never be shared. If, at any time, you wish to have your pet’s photo or story removed, please alert one of our doctors.

Monday	9:00am – 5:00pm
Tuesday	10:00am – 7:00pm
Wednesday	9:00am – 5:00pm
Thursday	10:00am – 7:00pm
Friday	9:00am – 5:00pm
Saturday	By Appointment Only
Sunday	Closed

Mammal History Form

Reason for presentation today

Cage Environment

Diet

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Emergency Info