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 Unknown Where 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 No What type of enclosure is your pet in and rough dimensions?*Do you use a hygrometer (humidity meter)?* Yes No How do you maintain the humidity?*How is the enclosure heated (light, heating pad, rock)?*Do you use thermometers?* Yes No What 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 No Does your pet spend time outside of the enclosure?* Yes No Explain*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 No What kind?* Any other reptiles or pets in the same enclosure?* Yes No What kind?* Any other pets in the house? Do they interact?*Any new changes at home?* Yes No Please 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 No What 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 No Please 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 No Brand/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 No Please explain:*Have they ever had any medical issues to your knowledge?* Yes No Please explain:*Have they ever laid eggs or given birth?* Yes No How 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.CAPTCHA Δ
