New Client Reptile Form

Your Name:

First Last

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:

Email:

Emergency Contact Name:

First Last

Emergency Contact Phone:

How would you like to receive reminders?

Reptile History

Pet(s) Name(s):

Species:

Age:

Sex:

male
female
i'm not sure

Length of Time Owned:

Acquired From:

Breeder
Pet Store
Other

Wild Caught or Captive Bred?

Have they been dewormed? If so, when?

How often is your pet handled?

Daily
Occasionally
Weekly
Never

Is your animal ever taken outside?

Yes
No

If so, for how long?

When was their last shed?

Any trouble shedding?

Yes
No

fecal consistency:

firm
loose
liquid

Hubandry

Type of enclosure:

Size of enclosure:

Where is cage located:

Type of cage furnishings:

Cage flooring:

How often is cage cleaned:

What type of disinfectant is used when cleaning cage?

Cage Enviroment

Type of lighting:

Light cycle:

Last time UV light was changed:

Is UV light blocked by glass or plexiglass?

Yes
No

Heat Source:

heating pad
heated rock
heat lamp
other

Humidity level:

Temperature within cage:

Please give the minimum, maximum and basking temperatures.

Nutrition:

Type of food offered:

Amount fed and how often:

When last fed:

Water source:

Additional Information

Any other pets? If yes, please specify:

Any other reptiles? If yes, please specify:

Reptiles housed together or separately?

Any new additions to the reptile population? If yes, please specify:

Is there any additional information you feel will assist in diagnosing your reptile?

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New Client Reptile Form

Reptile New Client

Reptile History

Hubandry

Cage Enviroment

Nutrition:

Additional Information

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Location

Riverside Animal Hospital

New Client Reptile Form

Reptile New Client

Reptile History

Hubandry

Cage Enviroment

Nutrition:

Additional Information

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Location

Riverside Animal Hospital