New Patient Check In- Exotics "*" indicates required fields Owner InfoName* First Last Address* Street Address City State ZIP Code Phone*Alternative PhoneEmail* Pet InfoName*Age*Color*Breed*If mixed, what sizeSex*Spayed/Neutered*Environment QuestionsWhat size is the cage or cages?*Where is the enclosure housed?*What the ambient temperature in the enclosure?*What temperature is the hotspot in the enclosure?*What is the humidity in the enclosure?*% day confined to enclosure*% day confined free roaming*How often is the cage cleaned?*What is used to clean the cage?*What substrate/bedding is used in the enclosure?*What other spaces does the pet have access to?*What types of enrichment or toys does the pet have?*Other Household PetsSpecies*Age(s)*Amount of contact between other pets above and this patient?*Do any other pets in the household have any known diseases?*If yes, which diseases?DietWhat food (brand) is the pet provided?*How often?*What other foods (treats, people food) does the pet eat?*How often?*How frequently is water offered?*ExercisePlease describe any exercise your pet receives and how often:Medical HistoryHas your pet had any medical concerns in the past / any history of illness? If so, please explain:*Has your pet ever had any vaccines? If so, please list the vaccines and most recent date of vaccination:*Is your pet currently on any medications? If so, please list medication, dose, and frequency:*Is your pet friendly with strangers? If not, provide details of what sort of situations he/she is not friendly inToday’s Visit InformationPrimary Concern today:*Duration of symptoms:*Getting better/worse?:*How is pet feeling?* Normal Slightly lethargic Very lethargic/weak Appetite:* Normal Decreased Not eating at all For how long?Drinking/urination:* Normal Decreased Increased For how long?Any vomiting?* No Yes Specify how many times/how many daysAny diarrhea?* No Yes Specify how many times/how many daysAny coughing, sneezing, or nasal discharge in the past two weeks?* No Yes Please describeHas your pet had a similar problem in the past?* No Yes Please give detailsIs there anything else we need to know?Please note: For patients being dropped off with us for the day: We will do an examination and basic testing/medications (such as giving pain meds to a painful pet) and then Dr. Jordan will give you a call to discuss the treatment plan. Typically the cost of the initial exam, tests, and meds is $150-300. If it is over $300, we will call you to discuss prior to performing tests/treatments. Once we have completed tests and treatments, we will call you and set up a pick up time. We will take payment at that point over the phone. Do you have any questions or concerns?CommentsThis field is for validation purposes and should be left unchanged.
