Rabbit 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

    Gender:

    Neutered:

    Is this your first Rabbit?

    Is this your first PET?

    Date of Birth:

    Date Acquired:

    Acquired from what source?

    ENVIRONMENT

    Indicate Height, Width & Length

    Substrate

    Does the rabbit use a litter box?

    Cage Accessories:

    Is cage shared with another rabbit?

    Gender of Cage Mate?

    Are they exposed to this pet?

    Is your pet supervised when it is outside of its cage?

    Where allowed when out of cage?

    NUTRITION

    Diet

    Vitamin & Mineral Supplements:

    MEDICAL HISTORY

    Please list any medical problems/Primary Complaint:

    Current treatments or supplements:

    Please list any previous medical problems:

    Current Appetite:

    Stools:

    Urination:

    Difficulty?

    Have you noticed:

    Describe details from above or other changes:

    Previous Vet Visits

    Date of last visit:

    Records Requested

    Received

    Previous Lab Tests / Diagnostics:

    Date of 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 the terms of service