Owner's Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Pet's Name(Required)Species(Required)Age/DOB(Required)Sex(Required) Male Female Unknown Where did you obtain your pet?(Required)Is your pet wild caught or captive bred?(Required)How long have you had your pet?(Required)Have you had this species of pet before?(Required) Yes No What type of enclosure is your pet in and rough dimensions?(Required)Do you use a hygrometer (humidity meter)?(Required) Yes No How do you maintain the humidity?(Required)How is the enclosure heated (light, heating pad, rock)?(Required)Do you use thermometers?(Required) Yes No What is the temperature gradient at night? During the Day? Basking spot temperature?(Required)Do you use a full spectrum UVB bulb and what kind?(Required)How often do you replace your UVB bulb and when was the last time this was done?(Required)How long are the lights on/off (day/night)?(Required)Any other bulbs in the enclosure?(Required) Yes No Does your pet spend time outside of the enclosure?(Required) Yes No Explain(Required)What is the substrate your pet is on?(Required)What is their water source and do you treat the water?(Required)Are there any plants/bushes/sticks/climbing structures?(Required)Is there a hiding area?(Required) Yes No What kind?(Required)Any other reptiles or pets in the same enclosure?(Required) Yes No What kind?(Required)Any other pets in the house? Do they interact?(Required)Any new changes at home?(Required) Yes No Please explain(Required)How often do you clean their enclosure?(Required)How often do you do partial water changes?(Required)How often do you do complete water changes?(Required)Do you use a water heater?(Required) Yes No What is the water temperature?(Required)Do you have a water filter? What kind?(Required)Do you test the water quality? How often? Any issues?(Required)Do you have a dry dock area for your pet?(Required) Yes No Please describe it(Required)DietPlease describe your pet’s diet (vegetables, beans, fruits, greens, insects/calcium dusting?/ gut loading?, small rodents (live or dead), any treats?(Required)Are they on any vitamins/supplements?(Required) Yes No Brand/what kind, and how often?(Required)How often do you offer food?(Required)Where do you feed them? In a separate enclosure?(Required)Do they have any seasonal behavioral changes?(Required) Yes No Please explain:(Required)Have they ever had any medical issues to your knowledge?(Required) Yes No Please explain:(Required)Have they ever laid eggs or given birth?(Required) Yes No How often do they defecate?(Required)How often do they shed (if applicable)? When was last shed? Any problems in past?What are your concerns today if any?Any other misc comments?Attach Medical RecordsMax. file size: 128 MB.CAPTCHA Δ
