Appointment Information

Owner First Name

Owner Last Name

Mobile Phone *

Email *

Enter email address

Avian Information

Patient Name

Species

How long have you had this bird?

Was your bird

Captive bred

Wild caught import

Unknown

Where did you get your bird from?

Does this bird have any reproductive history?

Yes

When did your bird last molt?

How often does your bird molt?

Has your bird ever received any vaccines?

Yes

If so, what vaccinations have they received and when were they last given?

Does your bird get wing trims?

Yes

What other pets, if any, do you have in the house?

When was the last animal added to your collection?

Have you or your bird had contact with other animals out the house in the last 30 days?

How often do you feed your bird?

Do you feed any of the following?

Pellets

Seed mixtures

Hay

Fruits or vegetables

Meat

Treats

Please elaborate

Do you use any nutritional supplements?

Yes

Please elaborate

What water supply do you provide?

Tap water

Bottled water

Other…

How is the water provided?

Bowl

Dripper system

Other…

Do you use any water supplements?

Yes

How often is the water changed?

Have you noticed any changes in feeding or drinking behavior?

Yes

Have you noticed any changes in droppings (fecal material, urine or urates)?

Yes

Where is the cage located?

Inside

Outside

Other…

What is the cage made of?

What is the cage size?

What kind of bedding is used?

What décor and furnishings are present?

Are bathing/spraying facilities provided?

Yes

How often is the cage cleaned?

What cleaning/disinfectant agents are used?

What percentage of time does your bird spend outside of the cage?

Does your bird have regular exposure to sunlight that is not through a window?

Yes

Is your bird exposed to full spectrum UVA and UVB lighting via a bird bulb or other source?

Yes

If you are using a bird light, how often is the bulb changed?

What is your pet's light/dark cycle?

Does anyone in the household smoke?

Yes

Do you use any aerosolized products or scent plug-ins?

Yes

Have there been any changes to the pet's environment in the last three months?

What is your primary reason for your visit today?

What health problems, if any, has your pet had previously?

Has your pet received any treatment in the last 30 days? If so, please elaborate?

Have you noticed any changes in your pet's behavior?

Have any other animals or people in the household had any illness in the last 30 days?

By checking this box and/or signing below, I acknowledge that Angleton Veterinary Clinic has a "No Staff Abuse" policy in place and they will not tolerate abuse of any kind towards staff, including verbal abuse. The abuse statement can be found below: "Our staff work hard during an often difficult and worrying time to provide you and your pet the best care. As such, we will not tolerate any rudeness or abuse towards any staff members. We appreciate your care for our family as we care for yours."

By checking this box, I certify that I am the owner/agent of the above described animal. I accept full financial responsiblity for this animal and have the authority to execute consent to any procedures necessary.

Signature

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Date

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Avian History Form

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