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Patient Information

Client Name*
Pet Name*
How long have you owned this pet?
Where did you acquire this pet?
Do you use any vitamin supplements?
If so, please list
Do you add these to the food or water?
- Yes
- No
If yes, how often?
Does your pet drink water from a bowl or bottle?
- Bowl
- Bottle
What type of enclosure is your pet kept in?
What is the average temperature of the enclosure?
What is the range of temperatures of the enclosure?
What substance(s) is (are) on the bottom of the enclosure?
What lighting systems are used in the pet’s enclosure?
How many hours for each lighting system?
How much time is your pet permitted outside the enclosure?
How many pets total are kept in this enclosure?
Briefly describe any past medical problems your pet has had.
Has your pet been exposed to pets outside your household? (Pet shops, shows, groomer?)
What other types of pets are in your household?
Have you recently added any new pets to your household? (Within the last year?)
Would you be interested in participating in or learning about our exotic pet blood donor program?
- Yes
- No
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Phone
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