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Reptile Medical History
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Owner's Name
*
First
Last
Today's Date
Appointment Date and Time (if already scheduled)
Date
Time
Email
*
Phone
Address
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
General History:
Pet's Name
*
Upload a photo of your reptile
Click or drag a file to this area to upload.
Pet's Breed
*
Pet's Age
*
How long have you owned this animal?
Where did you acquire this animal?
Pet Store
Breeder
Other
How often is this animal allowed outside the cage?
How often is this animal handled?
Type of cage:
Wood
Wire
Aquarium
Other
Size of cage:
Where is the cage located?
How often is the cage cleaned & with what products?
What type of bedding do you use?
What type of lighting is offered?
Fluorescent
Incandescent
Ultraviolet
Heat Lamps
Other
Brand and # of hours left on
Brand and # of hours left on
Brand and # of hours left on
Brand and # of hours left on
Brand and # of hours left on
Is the lighting on automatic timers?
Yes
No
Do you soak the animal in a separate container?
Yes
No
If so, how often?
How do you heat the cage? Select all that apply
Overhead Lamp
Ceramic Heater
Under Cage Heating Pad
Room Heat
Other
If other, please describe:
What is the temperature of the warmest spot in the cage during the DAY?
What is the temperature of the coolest spot in the cage during the DAY?
What is the temperature of the warmest spot in the cage during the NIGHT?
What is the temperature of the coolest spot in the cage during the NIGHT?
The temperatures above are:
Estimates
Thermometer Readings
Do you mist the cage or add humidity?
Yes
No
If so, how often?
Water is offered by:
Water Bottle
Water Dish
Drip System
Other
If other, describe:
What type of food is offered?
Vegetables
Fruits
Pellets
Animals/Fish
Vitamins
Other
Type and quantity
Type and quantity
Type and quantity
Type and quantity
Type and quantity
Type and quantity
Past medical problems:
Do you plan on boarding your pet in the future?
Yes
No
Do we have your permission to post any photos or videos on our hospital website, training guides, and/or Facebook, TikTok or Instagram?
*
Yes, you have permission.
No, you do not have permission.
Phone
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