Patient Forms

At Exotic Animal Veterinary Center, we offer patient forms online so you can complete them in the convenience of your own home or office.

Client & Patients Registration Form

Thank you for giving us the opportunity to care for your pet(s). So that we may become beter acquainted, please complete the following:

Client Name (Owner's Name):

Significant Other:

Address: *

Phone Numbers (Please check primary number)

Cell:

Home:

Work:

Significant Other:

Email:

Birthday (Clients):

Referred By:

Patient Name:

Breed:

Color(s):

Gender:

MFUnknown

Spayed/Neutered? (Y/N check boxes underneath)

If Avian, how do you know?

EggDNADimorphism

Is your pet microchipped?

If so, microchip number:

Birthdate / Age:

Do you currently have pet insurance?

Treatment Authorization and Information / Photo Release

I hereby authorize Exotic Animal Veterinary Center (EAVC) to perform medical and diagnostic/surgical procedures on this animal as required for diagnosis and treatment. I understand that I can terminate treatmant at any time by contacting the doctors and/or staff.

EAVC and its staff are leader and teachers in the veterinary medicine field, thus case information and/or photos may be used in teaching, forms continuing eduation, website, veterinary literature, and the like. Please read and circle one of the following options:

All fees are due at the time of services rendered. Deposits of 50% to 100% are required for all surgical procedures, drop-offs, and emergencies.

Exotic Animal Veterinary Center MAY or MAY NOT take photographs of me and my pet(s) for use In publicity, illustration or web content

MayMay Not

I agree that Exotic Animal Veterinary Center the right to photograph me and/or my pets and to use these images with or without my name and for any lawful purpose

I have read and accept the preceding obligations.

OWNER(S) SIGNATURE:

DATE:

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Physical Exam - Avian (Psittacine/Passerine)

Date Of Exam:

Patient Name:

Age

Male or Female

Owner Name:

Best Contact Number

History (Subjective):

Presenting Complaint:

Duration of symptoms:

Sudden onset?

Gradually getting worse? If yes, for how long?

Confirm breed of bird, is bird flighted?

Last veterinary visit:

Any bloodwork done?

Any viral testing done?

Any vaccines given?

Other medical history:

Current medications (strength, dosage, and frequency):

For how long have you had pet in household?

Where did you get pet from?

Husbandry - Diet:

What type of food do you offer (pellets, fruits, vegetables, nuts, ect)?

What percent of diet is seeds?

Is pet an egg layer?

When was the last egg laid?

Was the egg normal vs. soft or discolored?

Do you supplement calcium?

What type of calcium supplement?

Any multi-vitamin supplements?

Amount/Frequency:

Husbandry - Habitat:

(Please check one):

Indoors alwaysIndoors always with some trips outside (weather dependent)Indoors/OutdoorsOutdoors mainly with some trips inside (weather dependent)Outdoors always

Is pet supervised when/if they are outside or out of the cage?

What type of enclosure is pet kept in?

Size:

Types of perches in cage:

What types of toys are in the cage? (metal or wood? treated or not?):

How often is cage cleaned and what is used to clean cage?

Does owner practice captive foraging?

Is pet housed with any other species of birds?

Additional questions/concerns:

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Physical Exam - Reptile

Date Of Exam:

Patient Name:

Age

Male or Female

Owner Name:

Best Contact Number

History (Subjective):

Presenting Complaint:

Duration of symptoms:

Sudden onset?

Gradually getting worse? If yes, for how long?

Any previous medical problems?

Last veterinary visit:

Deworming?

Current medications (strength, dosage, and frequency):

When were medications last given?

For how long have you had pet in household?

Where did you get pet from (wild caught, captive bred, unknown?)

How often is pet handled?

Has the pet gone through brumation (hibernation?)

Have there been any recent changes in diet, environment, or husbandry?

Husbandry - Habitat:

How big is the tank/enclosure?

Is there a heat source?

Heat type?

Temperature gradient or range?

Is a thermometer used?

Where is it placed relative to heat source?

What is the humidity level?

Is hygrometer used?

Bedding type:

Depth of burrowing spaces:

Cage furniture and accessories:

Fake or live plants:

What cage cleaning methods are used?

Frequency of cleaning?

Are any pesticides, aerosol sprays, or chemicals used in the immediate vicinity of the pet?

Lighting:

UVA & UVB light?

When was the last UVB bulb changed?

Other light source:

Any exposure to direct sunlight (not through glass):

Frequency/Duration:

Soaking:

Do you soak your pet in warm water?

Frequency/Duration:

How long was the last shed?

Was it a complete shed?

Husbandry - Habitat:

Primary diet (alive or dead):

Amount/Frequency:

Source:

How long are prey items kept in with pet?

If live prey is offered, are they gut loaded?

Vitamins or supplements?

Amount/Frequency:

When did the pet last eat?

Water source:

City water or local well How are chlorine or chloramine removed?Bottled waterDistilled waterReverse-osmosis

Aquatic Turtles:

Is filter being used, how often is it changed?

Frequency of water change?

Full change?

Partial change?

Is the water heated?

Temperature range?

Is any type of water testing done?

If yes, please provide latest results:

Is a haul out area available?

Additional questions/concerns:

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Physical Exam - Rabbit, Guinea Pig, Chinchilla

Date Of Exam:

Patient Name:

Age

Male or Female

Owner Name:

Best Contact Number

History (Subjective):

Presenting Complaint:

Duration of symptoms:

Sudden onset?

Gradually getting worse? If yes, for how long?

Any previous medical problems?

Last Veterinary Visit:

Any bloodwork done?

Current medications (strength, dosage, and frequency):

When were medications last given?

For how long have you had pet in household?

Where did you get pet from?

For guinea pigs:

Are you giving your pet Vitamin C?

Husbandry - Diet:

Hay type:

Amount/Frequency:

Source:

Vegetable type(s):

Amount/Frequency

Pellet type:

Amount/Frequency:

Water bowl or bottle:

Husbandry - Habitat:

(Please check one):

Indoors alwaysIndoors always with some trips outside (weather dependent)Indoors/OutdoorsOutdoors mainly with some trips inside (weather dependent)Outdoors always

Is pet supervised when/if they are outside or out of the cage?

Housing:

(Please check one):

Free room of houseHas own roomCage/Pen/Hutch

Exercise time (frequency and area):

Litter box trained?

Litter type:

Hay in box?

Is pet bonded to another pet?

Any other pets in home, what kind?

Additional questions/concerns:

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Exotic Animal Veterinary Center
171 N Altadena Drive STE 120
Pasadena CA 91107
(626) 405-1777

Consent for Treatment and/or Admission

Client's Name:

Species:

Sex:

I, the undersigned owner, authorized agent of the owner or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that I am/I am not (circle one) over eighteen years of age, and hereby consent to the examination of this pet by staff veterinarians at this veterinary practice. I also agree that after consultation with me, the hospital’s doctors may prescribe medication for, treat, hospitalize, sedate, anesthetize and/or perform surgery on this animal. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. Should some unexpected life-saving emergency care be required and the attending veterinarian be unable to reach me, this practice’s staff has my permission to provide such treatment and I agree to pay for all related fees.

I understand that an estimate of the costs for veterinary services will be provided to me and that I am encouraged to discuss all fees attendant to such care before services are rendered and during this pet's ongoing medical treatment. If this animal is hospitalized, I agree to pay a deposit of 50% of the estimated fees and assume financial responsibility for the balance of all services rendered on a credit card at the time the pet is discharged from the hospital. In the event the pet is hospitalized for more than twenty-four hours and the attending doctor is unable to reach me, I understand it is my responsibility to call the hospital at least every twenty-four hours to inquire as to the medical status of my pet and the fees incurred for medical services up to that day. In the event of an open balance, I agree to make a monthly payment including a financing fee equal to 1.5% of the unpaid balance.

I understand that veterinary care during night time hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of personnel may not be provided during these hours. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. I authorize the following amount towards my pets treatment while at EAVC:

$92-$200$200-$500$500-$1000Over $1000

I further agree that either I, or an authorized agent of mine, will pick up this pet and pay for all accrued charges within five days after receiving written or oral notification that this animal is ready to be released from the hospital. Such notice will be given at the address maintained on the hospital's patient/client record. I agree that if I fail to comply with this policy, this practice may handle this abandonment in the best interests of the pet and the hospital and I will still be responsible for all fees incurred.

The most up-to-date contact information:

Address:

Phone Number:

Please select yes if over 18yrs old

YesNo

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How Are We Doing?

Please Tell Us What You Think

The exterior of the practice is well-kept and attractive

YesNo

The interior of the practice is clean, odor-free, safe and professional appearing.

YesNo

The appearance of our healthcare team is professional.

YesNo

Our receptionists were knowledgeable and courteous when I called.

YesNo

The technicians and/or assistants were knowledgeable and courteous to my pet and I.

YesNo

The amount of wait time before, during and after my appointment was acceptable.

YesNo

The veterinarian completed an exam of my pet, addressed my concerns and made recommendations clearly and in a way I understood.

YesNo

The healthcare team answered any questions I had.

YesNo

The checkout procedure was easy, convenient and timely.

YesNo

The service and care my pet and I received in relation to the cost was fair and a good value.

YesNo

I will recommend Exotic Animal Veterinary Center to others.

YesNo

Comments:

Please leave your name, phone number, and/or email address if you would like us to contact you:

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New Patient Form
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History Form - Bird
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History Form - Reptile
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History Form - Guinea Pig, Chinchilla
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Treatment Admission Form
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EAVC Client Survey
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Client & Patients Registration Form

Treatment Authorization and Information / Photo Release

Physical Exam - Avian (Psittacine/Passerine)

Physical Exam - Reptile

Physical Exam - Rabbit, Guinea Pig, Chinchilla

Exotic Animal Veterinary Center171 N Altadena Drive STE 120Pasadena CA 91107(626) 405-1777

Consent for Treatment and/or Admission

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Exotic Animal Veterinary Center
171 N Altadena Drive STE 120
Pasadena CA 91107
(626) 405-1777