Reptile 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

    First Name

    Last Name

    Work Phone

    Cell Phone

    Home Phone

    Email

    Pet's Name

    Species (SNAKE ONLY):

    Species (LIZARD ONLY):

    Species (TURTLE ONLY):

    List specific type, if applicable:

    Gender

    Is this your first reptile?

    Date of Birth:

    Date Acquired:

    Where from?

    ENVIRONMENT

    Habitat Dimensions:

    Cage Material

    Is there a Thermometer in the cage?

    If so, what location in cage?

    Temperature

    Basking Site

    NOTE: Indicate as temperature in °F.

    Daytime

    NOTE: Indicate as temperature in °F.

    Nighttime

    NOTE: Indicate as temperature in °F.

    How is the cage heated?

    Humidity Level:

    Humidity Method

    Is there an ultraviolet (UVB) light in the cage?

    Size / Watts

    Does your pet get natural sunlight?

    Is anything (glass / plastic) located between light source & reptile?

    Substrate

    Depth of Substrate

    Please indicate number of inches.

    Frequency of Complete Cleaning

    Do you soak your reptile?

    For how long?

    How often?

    Is cage shared with another animal?

    Where is the cage located in the
    house?

    Describe other cage accessories (hiding areas, branches, water
    bowls, etc.):

    NUTRITION

    Diet (Please describe in detail)

    Amount Fed

    Frequency Fed

    Vitamin & Mineral Supplements:

    If insects are fed, are they gut-loaded?

    Current Appetite:

    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:

    Describe:

    Former Vet Visits

    Doctor's Name:

    Date of last visit:

    Doctor's Phone

    Doctor's Clinic:

    Records Requested

    Records 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