Reptile Pre-Appointment Questionnaire Owner's Name(Required) First Last Name of person attending appointment(Required) First Last Email(Required) Pet's Name(Required)Appointment Date(Required) MM slash DD slash YYYY Do you need an estimate for your appointment?(Required) Yes No If your pet has lab work, how would you like the results communicated to you?(Required) Text Message Email Phone Call How old is your reptile?(Required)Date acquired(Required) MM slash DD slash YYYY Gender(Required) Male Female Gynandromorphic (Rare) Unsure Has the patient ever laid eggs?(Required) Yes No Unsure If so, how long ago?When did your reptile last shed?(Required)Was the shed complete?(Required) Yes No Does not shed How often does your pet soak?(Required)Have you obtained any new reptiles in the last 6 months?(Required) Yes, this pet. No Yes, a reptiles other than this one. What type of enclosure is your reptile housed in?(Required) Glass Acrylic PVC High-density polyethylene Mesh Other What type of substrate do you use?(Required) Sand Coco Husk Paper Astroturf Sphagnum Moss Cypress Mulch Other How often is the substrate cleaned or changed?(Required)What are the dimensions of the enclosure?(Required)Where in the house is the enclosure located?(Required)List all live plants in the enclosure:(Required)What cleaning products do you use?(Required)What else is in the cage? I.e Toys, accessories, other reptiles(Required)What humidity level is maintained in the enclosure and how do you keep it maintained?(Required)What is the heat source (NOT light) and where is it located?(Required)How many teperature sensors do you have in the enclosure and what range of temperature do you keep the warm and the cool sections of the enclosure?(Required)Do you provide UVA and UVB lighting?(Required) Yes No Unsure What type of bulbs do you use?(Required) Strip bulbs Can lighting Mercury vapor Unsure Other Is there a screen between the bulbs and the enclosure?(Required) Yes No Unsure Other Approximately how many hours a day of lighting does your reptile receive?(Required)How often are the lights changed? When were they last changed?(Required)What do you feed your reptile? Please be very specific, including amounts, brands, and occasional treats.(Required)How often do you feed your reptile?(Required)What supplements do you use? (Be specific with brand names if possible, Calcium, Vitamin D3, Dusting, Garden, etc.)(Required)How do you provide water in the enclosure?(Required)How often is the water changed?(Required)If you have an aquatic reptile, how often is your water changed? When was the last time a water quality test strip was used? And, how often is you pet out of the water or dry docked?Are there any current concerns? Please give details of when any issues started and a timeline of any development or behavior changes.(Required)If there are concerns, have there been any changes in the home environment around that time? (Furniture change, construction, new people, new scents or perfumes, etc?)I understand that I assume financial responsibility for all services rendered, and that payment is due on the date of the appointment. The individual bringing my pet to the appointment is authorized to request services and communicate what my pet needs.(Required)
