Reptile History Form Step 1 of 2 50% Today's Date* MM slash DD slash YYYY Owner Name*Co-Owner NamePronouns (Optional)Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email AddressHome NumberWork NumberCell Number*Co-Owner Work NumberCo-Owner Cell NumberName of Previous ClinicPhoneRecommended by Whom?Place of EmploymentEmergency Contact*Will be used if you cannot be reached. Your ReptilePet Information*NameSpeciesSexID #ID TypeAgeDate AcquiredWild CaughtDomestic bredDoes the animal roam freely?* Yes No Do you have a thermometer in cage?* Yes No Describe cage enclosure (dimensions, substrate type, lighting, accessories)UV-b light? If so please let us know how often it is replaced.How often is the cage cleaned and what type of method/solution is used?DietCommercial/Pelleted Food (Brand)InsectsLive/Frozen PreyTable FoodsHow is water offered? (cup, bowl, tube)Hours of darkness a day Recent Changes in diet?Other PetsOther reptiles at home?* Yes No Where do they reside?List other types of reptiles Are any other reptiles sick? Yes No Have any died? Yes No Please provide details of their deathList other pets on the premises Health HistoryWhat signs have you noticed regarding this reptile?What tests have been performed? Bloodwork Fecal Parasite check List vaccines and datesVaccineDate Has this reptile seen another veterinarian, if so when and why?CommentsAcknowledgementsMany drugs that have been approved for use in humans and/or animals have also been proven to be safe and effective in species for which the drugs are not labeled. Our veterinarians, often by necessity, must recommend, administer and prescribe drugs that are considered extra-label. I authorize my pet's veterinarian to use extra-label drugs.Please initialI understand Mariposa Veterinary Wellness Center is not a 24 hour facility, and on occasion there may be pets in the facility in the absence of personnel. The clinic is equipped with smoke detectors and an alarm system capable of dispatching emergency responders immediately. Veterinarians will discuss options for overnight care and monitoring when appropriate.Please initialI grant to Mariposa Veterinary Wellness Center, its representatives and employees the right to take photographs of me & my property in connection with my visit. I authorize Mariposa Veterinary Wellness Center, its assigns & transferees to copyright, use & publish the same in print and/or electronically. I agree Mariposa Veterinary Wellness Center may use such photographs of me with or without my name & for any lawful purpose, including for example such purposes as publicity, illustration, advertising & web content.Please initialI have read and understand the above.Date* MM slash DD slash YYYY Signature*CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
