Exotic Mammal Pre-visit Questionnaire Exotic Mammal Questionnaire (This form helps us to get a better understanding of how your exotic mammal 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 pet’s name? * What is the birth date or estimated age of your pet? * Gender? * Male Male/Castrated Female Female/Spayed Unsure Is your pet vaccinated? If so please list when the last vaccination was given (rough dates are okay if you aren't sure). * Is your pet on any heartworm prevention? If so, in what form? * 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 pet had any previous medical concerns? * Yes No Is your pet on any current medications? If so please list what medications they are on. * How long have you had your pet and where did you get it from? * 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. * Where does your pet live? * Indoors Outdoors Does your pet have play time outside of their normal enclosure? * Yes No Do any other animals live with your pet? * Yes No Lastly, how did you first hear about Exotic Vet Care? * Google (or other search engine) Social media (Facebook, Instagram, YouTube etc) Recommended by a friend or colleague I saw the clinic from the street OtherOther Captcha Submit If you are human, leave this field blank.
