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Small Mammal Medical History
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Pet's Name
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Upload a photo of your small mammal
Click or drag a file to this area to upload.
Pet's Species
Pet's Age
Appointment Date and Time (if already scheduled)
Date
Time
Reason for visit?
Have you been to our satellite office, Union Pet Hospital, recently?
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No
Are you interested in Pet Insurance?
Yes
No
Has your pet had any recent medical problems?
Yes
No
Does your pet have any chronic medical problems?
Yes
No
Does your pet have any allergies?
Yes
No
If yes, to what?
Do you plan on boarding your pet?
Yes
No
Is your pet micro-chipped?
Yes
No
Is your pet currently on any medications?
Yes
No
If yes, please list:
Where & when did you acquire your pet?
What type of cage & bedding are you using?
Where is the cage located?
How much time is spent outside the cage?
What is your pet's diet?
How much/often are you feeding?
Has your pet been tested for intestinal parasites in the past 12 months? (Fecal exam)
Yes
No
Has your pet shown any of the following signs or symptoms? If yes, please check all that apply
Unusual Body Odors
Shaking Head/Ears
Unusual Discharge
Coughing
Sneezing
Wheezing
Gagging
Choking
Squinting
Itching
Hair Loss
Skin Problems
Poor Hair Coat
Vomiting
Diarrhea
Lumps/Bumps
Panting
Weakness
Limping
Lameness
Stiffness
Listless
Tremors/Seizures
Has your pet shown significant change in any of the following?
Character of bowel movements?
Yes
No
Appetite?
Yes
No
Frequency or amount of urination?
Yes
No
Drinking?
Yes
No
Weight gain or loss?
Yes
No
Behavior?
Yes
No
EPR CLIENTS: If your pet is visiting us from the Pet Resort, please leave a number where the veterinarian can contact you after your pet has been examined.
Do we have your permission to post any photos or videos on our hospital website, training guides, and/or Facebook, TikTok or Instagram?
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Yes, you have permission.
No, you do not have permission.
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