Step 1 of 250%InstagramThis field is for validation purposes and should be left unchanged.(This form helps us to get a better understanding of how your bird is cared for at home and must be filled PRIOR TO the appointment)Name(Required) Prefix First Last Suffix Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) What is your bird’s name?(Required)What type/breed of bird do you have?(Required)What is the birth date or estimated age of your bird?(Required)Gender?(Required) Male Female UnsurePrior vet/clinic information(Required)What are the symptoms of concern for your pet and when did you first notice?(Required)Have you done any home remedies or treatments for your concerns? If so, please list what and how often you've done this.(Required)Has your bird had any previous medical concerns?(Required)Is your bird on any current medications? If so please list what medications they are on.(Required)Is your bird microchipped?(Required) Yes NoHow long have you had your bird and where did you get it from?(Required)How often does someone interact with your bird?(Required)Can you describe how you interact with your bird? (ie head scratches, rub the back area. give kisses, etc).(Required)Cage/enclosure size (dimensions) and what is it made of?(Required)What type of perches are used in the cage?(Required)Cage location?(Required)Temperature/humidity?(Required)Type of lighting/bulb/watts/location on enclosure (filtered through screen/glass)/hours is on/off?(Required)Type of flooring/substrate/bedding?(Required)How often do you clean the cage/enclosure?(Required)Does your bird get bathed in a water dish or outside of the enclosure? How often?(Required)Type of diet, how much do you feed and how often? Please list brand name, daily amounts of each food and list any supplements you are using.(Required)How many hours of complete night-time (with no noise/lighting) does your bird receive?(Required)If your bird is female have they laid any eggs? If so, how many and when did this occur?(Required)Other pets?(Required) Yes NoDoes anyone in the house smoke?(Required) Yes NoLastly, how did you first hear about Exotic Vet Care?(Required) Google (or other search engine) Social media (Facebook, Instagram, YouTube etc) Recommended by a friend or colleague I saw the clinic from the street OtherCAPTCHAΔ
