Avian (Bird) History Form

    Thank you for choosing Ness Exotic Wellness Clinic. In order to personalize your experience and have a clear understanding of your pet's current health status, we need you to fill out the history form below.

    Today's date

    Your First Name

    Your Last Name

    Your Work Phone

    Cell Phone

    Home Phone

    Your Email

    Pet's Name

    Species:

    Is this your first bird?

    Hatch date

    Date Acquired

    Where from?

    Form of Identification

    Gender

    How Determined?

    Please list other pets you have at home and if they have any current illness:

    ENVIRONMENT

    Approximate bird cage dimensions

    Indicate Height, Width & Length

    Where is the cage located in the house?

    Describe the perches in the cage (different sizes, material type, location, etc.)

    Describe other cage accessories (toys, mirrors, etc.):

    Are there any other birds sharing this cage or in direct contact?

    Are there any smokers in the house?

    Does your bird spend time out of the cage?

    How much?

    Is your bird ever unsupervised outside of the cage?

    Under what circumstances?

    NUTRITION

    Diet Provided

    What the bird actually eats:

    Supplements provided:

    Has your bird been eating normally?

    If not, describe:

    MEDICAL HISTORY

    Please list any medical problems:

    Current treatments or supplements:

    Please list any previous medical problems:

    Have you noticed changes in:

    Describe

    Have you noticed:

    Copy of Describe when and duration:

    Former Vet Visits

    Doctor's Name

    Date of last visit:

    Docor's Phone

    Doctor's Clinic

    Records Requested

    Received?

    Previous Lab Tests / Diagnostics:

    Date of last testing:

    Tests Conducted:

    Other Tests:

    Abnormal Results:

    Results Requested:

    Sent to Clinic?

    Your Signature

    To the best of my knowledge, the information provided above and on the patient history form is accurate and complete. I authorize you to contact my referring veterinarian if clarification of medical history is needed or to acquire previous veterinary records, I understand that payment is due at the time services are rendered. I agree to pay all charges at the time my pet is discharged.

    Data Privacy and Consent:

    I agree to theterms of service