Bird Pre-visit Questionnaire Bird Questionnaire (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 * 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 your bird’s name? * What type/breed of bird do you have? * What is the birth date or estimated age of your bird? * Gender? * Male Female Unsure 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 bird had any previous medical concerns? * Is your bird on any current medications? If so please list what medications they are on. * Is your bird microchipped? * Yes No If you are human, leave this field blank. Next
