Rabbit Pre-visit Questionnaire Rabbit Questionnaire (This form helps us to get a better understanding of how your rabbit is cared for at home and must be filled PRIOR TO the appointment) Name * Name First First Last Last Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * What is the name of your rabbit? * What breed is your rabbit? * What is the birth date or estimated age of your rabbit? * Gender? * Male Male/Neutered Female Female/Spayed Unsure How long have you had your rabbit and where did you get it from? * Prior vet/clinic information * What are the symptoms of concern for your pet and when did you first notice? * Have you done any home remedies or treatments for your concerns? If so, please list what and how often you've done this. * Has your rabbit had any previous medical concerns? * Is your rabbit on any current medications? If so please list what medications they are on. * Is your rabbit microchipped? * Yes No What do you feed your rabbit/s? Please list daily amounts of each food. (Very important!) * If you are human, leave this field blank. Next
