5201 Virginia Beach Blvd.
Virginia Beach, VA 23462
(757) 473-0111
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CLIENT FORMS
AVIAN HISTORY FORM
INTERNATIONAL HEALTH CERTIFICATE
NEW CLIENT / NEW PATIENT FORM
PET CARE VETERINARY HOSPITAL FINANCIAL POLICY
PRE-VISIT HISTORY QUESTIONNAIRE
REPTILE HISTORY FORM
VIRGINIA VETERINARY DISCLOSURE FORM
FEAR FREE FORMS
AVIAN FEAR FREE PRE-VISIT QUESTIONNAIRE
FEAR FREE PRE-VISIT QUESTIONNAIRE
PET MEMORIALS
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BACK TO WEBSITE
CLIENT FORMS
AVIAN HISTORY FORM
INTERNATIONAL HEALTH CERTIFICATE
NEW CLIENT / NEW PATIENT FORM
PET CARE VETERINARY HOSPITAL FINANCIAL POLICY
PRE-VISIT HISTORY QUESTIONNAIRE
REPTILE HISTORY FORM
VIRGINIA VETERINARY DISCLOSURE FORM
FEAR FREE FORMS
AVIAN FEAR FREE PRE-VISIT QUESTIONNAIRE
FEAR FREE PRE-VISIT QUESTIONNAIRE
PET MEMORIALS
Avian History Form
Required fields are marked(*)
Owner's Name:
*
First
Last
Owner's Email:
*
(For copy of this form for your records)
Owner's Phone Number:
*
Bird's Name:
*
Sex:
*
Male
Female
Unknown
Species:
*
How was the sex determined?
Endoscope
DNA (blood test)
Other
If "Other" above, please describe:
Identification:
*
Microchip
Tattoo
Band
Show Number:
Bird is a:
*
Pet
Breeder
If breeder (bird has produced young or eggs) please describe:
Date Acquired:
MM slash DD slash YYYY
How was bird acquired?
Wild Caught
Domestic Bred
Has the bird been quarantined?
Commercial
Private
No
Length of quarantine?
Other birds kept in same quarantine?
Yes
No
Did any of the birds die or become ill while in quarantine?
Yes
No
If "Yes" please share details:
Bird is kept in a:
*
Cage
Aviary
Bird stand in the house
Wings trimmed?
*
Yes
No
Other birds in the same cage or aviary?
Yes
No
If "Yes" above, please list:
List other birds on the premises, indoors and outdoors:
Are any of these birds sick?
Yes
No
Have any of these birds died?
Yes
No
If "Yes" above, please give details:
List other pets in the home:
*
List toys available to the bird:
What do you use on the bottom of the cage:
Can the bird reach it?
Yes
No
Bird is kept:
Indoors
Outdoors
If indoors:
In a separate room
With family
Frequency of cage cleaning:
*
Method/frequency of cleaning food/water receptacle:
How many hours of darkness does the bird have each day:
*
Diet: (Check all that apply)
*
Pelleted food
Seeds
Combination
Table foods
Pelleted brand food:
Describe eating habits:
Amount offered to bird each day:
Amount bird eats each day:
How is water offered:
Cup
Sipper tube
Recently added food or dietary changes:
What signs have you noticed regarding this bird, this incident: (Check all that apply)
*
Diarrhea
Vomiting
Blindness
Constipation
Tail-bobbing
Breathing difficulty
Perching difficulty
Fainting
Fluffed feathers
Drooping or injured wings or legs
Eye/ear/nostril bleeding or injury
Lameness
Bitten by another bird/pet
Feather picking/loss
Skin bleeding
Coughing/hoarse
Change in personality
Change in vocalization
Change in stool consistency
Change in appetite
Excessive water consumption
What other tests has the bird been given: (Check all that apply)
Chlamydophila
Psittacine beak and feather disease
Polyomavirus
Parasites
Other
Has the bird been seen by any other veterinarian:
Yes
No
If yes, when and why:
What vaccines has the bird been given and the dates given:
*
Has the bird been dewormed:
*
Yes
No
Unknown
What treatment was used:
Additional comments (your opinions regarding this illness/accident):
I have received and read the brochure on chlamydiosis:
*
Yes
No
I was referred to your clinic by:
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Pet Memorial
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*
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Pet's Name
*
Your Email
*
Pet's Photo
*
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Comments
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