Owner's Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* Pet's Name*Species*Age/DOB*Sex* Male Female UnknownWhere did you obtain your pet?*Is your pet wild caught or captive bred?*How long have you had your pet?*Have you had this species of pet before?* Yes NoWhat type of enclosure is your pet in and rough dimensions?*Do you use a hygrometer (humidity meter)?* Yes NoHow do you maintain the humidity?*How is the enclosure heated (light, heating pad, rock)?*Do you use thermometers?* Yes NoWhat is the temperature gradient at night? During the Day? Basking spot temperature?*Do you use a full spectrum UVB bulb and what kind?*How often do you replace your UVB bulb and when was the last time this was done?*How long are the lights on/off (day/night)?*Any other bulbs in the enclosure?* Yes NoDoes your pet spend time outside of the enclosure?* Yes NoExplain*What is the substrate your pet is on?*What is their water source and do you treat the water?*Are there any plants/bushes/sticks/climbing structures?*Is there a hiding area?* Yes NoWhat kind?*Any other reptiles or pets in the same enclosure?* Yes NoWhat kind?*Any other pets in the house? Do they interact?*Any new changes at home?* Yes NoPlease explain*How often do you clean their enclosure?*How often do you do partial water changes?*How often do you do complete water changes?*Do you use a water heater?* Yes NoWhat is the water temperature?*Do you have a water filter? What kind?*Do you test the water quality? How often? Any issues?*Do you have a dry dock area for your pet?* Yes NoPlease describe it*DietPlease describe your pet’s diet (vegetables, beans, fruits, greens, insects/calcium dusting?/ gut loading?, small rodents (live or dead), any treats?*Are they on any vitamins/supplements?* Yes NoBrand/what kind, and how often?*How often do you offer food?*Where do you feed them? In a separate enclosure?*Do they have any seasonal behavioral changes?* Yes NoPlease explain:*Have they ever had any medical issues to your knowledge?* Yes NoPlease explain:*Have they ever laid eggs or given birth?* Yes NoHow often do they defecate?*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.Δ
