Gilbertsville Vet – Reptile / Amphibian Form Old

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We are pleased to welcome your new reptile/amphibian to Gilbertsville Veterinary Hospital. Please take a few minutes to fill out this form as completely as you can. If you have any questions please contact our practice at (610) 367-4744 and we will be glad to help you. We look forward to working with you in maintaining your pet’s health.

The husbandry, feeding and background of your reptile/amphibian is important information that our veterinarians use to guide them with the treatment and diagnosis of your pet. If you are unclear about any of the information on this document, one of our veterinarians will be glad to help you at your pet’s first visit with our practice.
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Date
First Name
Last Name
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Cell Phone
Home Phone
Email
Pet Name
Species
Sex
Birthday or Estimated Age
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Please Select
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DNA
Endoscopy
Visual
Other
How was the sex of your pet determined?
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Captive bred
Wild caught import
Unknown
Origin
How long have you had this pet?
From where did you obtain this pet?
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Yes
No
Does this pet have a reproductive history?
When did your pet last shed?
How often has your pet been shedding?
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Yes
No
Unknown
Do you have other reptiles or pets?
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When was the last reptile added to your family?
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Wellness
Illness
Second Opinion
What is the primary reason for your pet's visit?
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If an illness exam or second opinion appointment; What is the primary complaint or what signs have you noticed? How long have these problems been present?
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What health problems has your reptile had previously, if any?
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Please Select
Please Select
Yes
No
Has your reptile received any treatments in the last 30 days?
If yes, please give details (what was used, dosage, how often, duration)
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Please Select
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Yes
No
Have you noticed any change in your reptile's behavior?
Please Select
Please Select
Yes
No
Have any other animals or persons in the household had any illness in the last 30 days?
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The Next section refers to Diet
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How often do you feed your pet?
Please Select
Please Select
Yes
No
Do you feed wild animals to your animal?
Frozen or thawed vegetables
Fresh vegetables
Frozen or thawed flowers
Fresh flowers
Frozen or thawed fruits
Fresh fruit
Frozen or thawed mice
Freshly killed mice
Live mice
Frozen or thawed rats
Freshly killed rats
Live rats
Frozen or thawed fish / birds
Freshly killed fish or birds
Live fish or birds
Please indicate if you feed any of the following:
Please indicate the following for the above questions the amount fed and type if applicable.
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Please Select
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Yes
No
Do you use nutritional supplements?
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Tap Water
Bottled Water
River/Rain Water
What water supply do you provide?
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Yes
No
Do you use any water supplements?
How often is the water changed?
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Have you noticed any changes in feeding or drinking behavior?
Have you noticed any changes in droppings (fecal material, urine & urates)? Please give details
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The next section will cover cage environment.
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Please Select
Please Select
Yes
No
Does your pet have a cage?
Please Select
Please Select
Arboreal (tall, climbing)
Terrestrial
Aquatic Cage Size?
What type of cage is used?
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Please Select
Plastic/fiberglass
Wood
Metal
Glass
What is the cage made of?
What decor & furnishings are present?
Is there ventilation (grill or mess)? If yes, size details.
Are bathing facilities provided? If yes, details.
How often is the cage cleaned?
What disinfectants are used?
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What heating equipment is used? Please provide the power watt used and if there is a thermostat.
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Yes
No
Are the heat sources screened from the animals?
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Yes
No
Can the animals touch or access the heat source?
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Yes
No
Is additional lighting provided inside the cage?
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Please Select
Light bulb
Fluorescent strip light
I do not use additional lighting
If additional lighting is used please indicate the type
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Please Select
Please Select
Yes
No
Is there ever access to direct sunlight (not through glass or plastic)?
If yes, how many hours per day or per week?
Do you measure the humidity in the cage? If yes, what is the level?
What are the day time temperatures? please include the hottest and coolest temperatures.
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Please Select
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Yes
No
Are these temperatures measured using a thermometer?
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Please Select
Yes
No
Does anyone in the household smoke?
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Please Select
Yes
No
Do you use aerosolized products?
Please Select
Please Select
Yes
No
Have there been changes in the reptile’s environment in the last 3 months?
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Previous Veterinary Facility name (if applicable):
Phone Number of Previous Veterinary Facility for us to call and request your pet's records (if applicable):
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I am the said owner or the agent for the above described pet and have the authority to execute this consent. I understand that I will be responsible for the cost of veterinary services, prescriptions, and product at the time they are rendered for my pet. I have read and understand this authorization and consent by typing my name below.
First Name
Last Name
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Type a question
Should be Empty: