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Small Mammal Wellness Form

Name

Owner First Name

Owner Last Name

Mobile Phone

Email *

Enter email address

Patient Name

How long have you had this pet?

Where did you get this pet from?

Has your pet ever received any vaccines?

Yes

No

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

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

When was the last animal added to your collection?

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

How often do you feed your pet?

Do you feed any of the following?

Pellets

Hay

Fruits or vegetables

Meat

Treats

Please elaborate

Please elaborate

Please elaborate

Please elaborate

Please elaborate

Do you use any nutritional supplements?

Yes

No

Please elaborate

What water supply do you provide?

Tap water

Bottled water

Other…

Please specify

How is the water provided?

Bowl

Dripper system

Other…

Please specify

How often is the water changed?

Have you noticed any changes in feeding or drinking behavior?

Yes

No

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

Yes

No

Where is the cage located?

Inside

Outside

Other…

Please specify

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

Is your pet supervised when out of the cage?

Yes

No

What is the cage made of?

What is the cage size?

What décor and furnishings are present?

What kind of bedding is used?

Is your pet litter trained?

Yes

No

Do you provide any bathing facilities?

Yes

No

What is your pet's day/night cycle?

How often is the cage cleaned?

What cleaning/disinfectant agents are used?

Does anyone in the household smoke?

Yes

No

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

Yes

No

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.

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