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

    Species (SNAKE ONLY):

    Species (LIZARD ONLY):

    Species (TURTLE ONLY):

    Gender

    Is this your first reptile?

    Date of Birth:

    Date Acquired:

    ENVIRONMENT

    Cage Material

    Is there a Thermometer in the cage?

    Temperature

    NOTE: Indicate as temperature in °F.

    NOTE: Indicate as temperature in °F.

    NOTE: Indicate as temperature in °F.

    How is the cage heated?

    Humidity Level:

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

    Does your pet get natural sunlight?

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

    Substrate

    Please indicate number of inches.

    Do you soak your reptile?

    Is cage shared with another animal?

    Describe other cage accessories:

    NUTRITION

    Diet

    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:

    Have you noticed:

    Former Vet Visits

    Date of last visit:

    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 the terms of service