The Pet Hospital of Granbury

1851 Acton Hwy
Granbury, TX 76049

(817)573-5003

www.pethospitalgranbury.com



Please complete and submit this form before your scheduled appointment.

Reptile/Aquatic New Patient Form

Referring Veterinarian (if applicable):

Client(s) First/Last Name: (required)
First Name (required)
Last Name (required)
Pet's Name (required)

Species (required)

Age/DOB/Hatch Date: (required)

Sex (required)

Male
Female
Unknown


Where did you obtain your reptile/amphibian? (required)

How long have you had your reptile/amphibian? (required)

Is your reptile/amphibian: (required)

Wild Caught
Captive Bred



HOUSING:
What type of enclosure does your reptile/amphibian live in? (required)

What are the dimensions? H______________ W_______________ L______________ (required)

Do you use a hygrometer (humidity meter)? (required)

Yes
No
NA


If yes, what is the humidity? (Type NA if Not Applicable)

How is the enclosure heated (e.g., light, heated pad, heat rock)? (Type NA if Not Applicable) (required)

What is the temperature? Day:______________ Night:_______________ Basking Site:_____________ (Type NA if Not Applicable) (required)

Do you use thermometers? (required)

Yes
No
NA


If yes, where are they located? (Type NA if Not Applicable) (required)

Do you use a full-spectrum UVB bulb? (required)

Yes
No
Unknown
NA


If not, what kind of bulb do you use? (Type NA if Not Applicable) (required)

How often is it replaced and when was the last replacement? (Type NA if Not Applicable) (required)

How long are the lights on/off: During the day__________________ Off at night__________________ (Type NA if Not Applicable) (required)

Does your pet spend time outside of the enclosure?: If yes, explain: (Type NA if Not Applicable) (required)

What is the substrate (bedding)? (Type NA if Not Applicable) (required)

What is the water source? (Type NA if Not Applicable) (required)

Are there plants, branches, or other climbing structures? (Type NA if Not Applicable) (required)

Is there a hiding area? If so, what kind? (Type NA if Not Applicable) (required)

Are there any other reptiles in the same enclosure? If so, what species? (Type NA if Not Applicable) (required)


FOR AQUATIC SPECIES:
How often do you change the water completely? Partially? (Type NA if Not Applicable) (required)

Do you use a water heater? (required)

Yes
No
NA


Does the aquarium have a filter? (required)

Yes
No
NA


Do you test the water quality? (required)

Yes
No
NA


Diet
Please fill in the percentage of the total diet and types of food in each category that your pet actually eats:
Leafy greens:

Legumes/beans:

Fruits:

Other vegetables:

Insects/small rodents: (select one) (required)

Live
Dead
NA


Pellets:

Other (including treats):

How often do you offer food? (required)

Where do you feed your reptile? (required)

Do you add vitamin or calcium supplements to the food? (required)

Yes
No
NA


If you do add vitamins or calcium supplements to the food, what kind/brand and how often? (Type NA if Not Applicable) (required)

If insects are fed, are they gut loaded? (required)

Yes
No
Unknown
NA


Other Information
Do you soak or bathe your reptile, and if so how often? (Type NA if Not Applicable) (required)

Do they have any seasonal behavior changes? (required)

Medical History
Has your reptile ever been checked for intestinal parasites? (required)

Yes
No
Unknown
NA


Has your reptile ever laid eggs? (required)

Yes
No
Unknown
NA


How often does your reptile defecate? (required)

How often does your reptile shed, and when was the last shed? (Type NA if Not Applicable) (required)

Did your reptile have any problems with their shed? (Type NA if Not Applicable) (required)

Check any boxes that apply to your pet: (required)
Mites
Wounds
Weight Loss
Weight Gain
Not Defecating
Anorexia
Diarrhea
Shedding Problems
Difficulty Breathing
Lethargy
Inactivity
Increased Appetite
Decreased Appetite
Limping
Vomiting
Deformed Limbs
Swollen Eyes
Other
Is there anything else you would like us to know today? (required)


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