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 UnknownWhere 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 NoWhat type of enclosure is your pet in and rough dimensions?(Required)Do you use a hygrometer (humidity meter)?(Required) Yes NoHow do you maintain the humidity?(Required)How is the enclosure heated (light, heating pad, rock)?(Required)Do you use thermometers?(Required) Yes NoWhat 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 NoDoes your pet spend time outside of the enclosure?(Required) Yes NoExplain(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 NoWhat kind?(Required)Any other reptiles or pets in the same enclosure?(Required) Yes NoWhat kind?(Required)Any other pets in the house? Do they interact?(Required)Any new changes at home?(Required) Yes NoPlease 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 NoWhat 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 NoPlease 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 NoBrand/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 NoPlease explain:(Required)Have they ever had any medical issues to your knowledge?(Required) Yes NoPlease explain:(Required)Have they ever laid eggs or given birth?(Required) Yes NoHow 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.CAPTCHAΔ
