Exotic Pre-visit History

Owner's Name*

First Last

Co-Owner's Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Co-Owner Phone*

Primary Cell Number

Email*

Enter Email Confirm Email

Whom may we thank for the referral?

Cancellation Policy:*

I agree to the cancellation policy

In order to help all of our patients, we require a 24 HR cancellation notice. If you are more than 7 minutes late for your appointment, we will reschedule for another time. Please check the consent box above.

A. (Who can bring my pet in for treatment) Other than you and the co-owner, are there any other persons (18 years or older) to whom you give primary responsibility for the care of your pets? (Authorized agents are not automatically entitled to make medical treatment decisions for your pet, unless you give permission in section B). If yes, please list them in the order you wish us to contact them in the event that you or the co-owner is not available.

Yes, the additional agents are listed below
No, there are no additional agents

Authorized Owner’s Agent #1 Name

First Last

Authorized Owner’s Agent #1 Phone

Authorized Owner’s Agent #2 Name

First Last

Authorized Owner’s Agent #2 Phone

B. (Who can discuss risks/benefits with veterinarian and make medical decisions for my pet). I understand that my veterinarian will need to communicate with me, the co-owner, or my authorized agent, prior to treatment of my pet(s) in order to obtain informed consent per the State of Wisconsin. For purposes of informed consent, I direct my veterinarian as follows: Informed consent may ALSO be provided by the agents above, in the order listed.

Yes
No

Electronic Consent

By typing my name below as my electronic signature, I certify that I am the primary owner listed above, I am at least eighteen (18) years of age, and this information is correct to the best of my knowledge. I further acknowledge that no guarantee has been made as to the results that may be obtained. I understand that complications may arise which cannot be predicted and that I will be held financially responsible for any veterinary medical care necessitated by complications. By typing my name below, I consent to the practice contacting me by e-mail and by text message for the purpose of health information and appointment reminders. I will ensure that I keep the practice informed of my up to date mobile number at all times, or if the number is no longer in my possession. PAYMENT IN FULL IS EXPECTED AT THE TIME OF SERVICE

Name

First Last

Date

Release of Medical Records

A. Wisconsin law requires written permission to release your pet's health records to certain third-parties (non-owners). Wis.Stat.453.075. Please indicate to whom you authorize us to release your pet's health records. Do you want us to release your pet's health records to other Veterinary Clinics?

Please list any and all Veterinarians, Humane Organizations/Rescues, Property Management Office Kennels & Pet Daycare, Groomers, Pet Insurance Companies, etc that you authorize us to release your pet's medical records to.

Pet Information

Pet's Name*

Species*

Breed*

Sex*

Color*

Date of Birth or Age*

Previous Veterinary Practice (if any)

What is the best phone number to reach you during your appointment?*

Is anyone in the house experiencing respiratory symptoms or is COVID positive?*

Yes
No

If intact female, any litters or clutches?

Yes
No

If yes, any complications?

Length of time in current household:*

How was pet acquired?*

Pet Idiosyncrasies:*

(Your pet's different behaviors or preferences)

Known Allergies:*

Does your pet have access to the entire house?*

Is your pet:*

Indoor
Outdoor
Indoor and Outdoor
Caged

Describe your pet’s enclosure (type/size/location/objects inside):*

Is your pet supervised when out of its enclosure?*

Yes
No

What bedding/substrate is used?*

Daytime Temperature in enclosure:*

Nighttime Temperature in enclosure:*

Humidity in enclosure:*

Type of lighting used:*

Timer Controlled?

Yes
No

Do any other pets share enclosure?*

How often is the enclosure sanitized?*

What cleaning products are used for this?*

Diet (brand and type of pellet/seed)*

Type of hay (if any)*

What percentage of daily feed is pellets?*

What percentage of daily feed is hay?*

What percentage of daily feed is fresh produce?*

Other types of food offered / how often:*

How long does it take for pet to eat each portion of food?*

Dietary supplements:*

Is fresh water provided daily?*

History:*

Describe any medical problems:*

Current medications:*

Reason for today’s visit:*

For illness / injury, please list date first noticed, changes observed during problem, and methods of treatment:*

Fear Free Questionnaire

As Fear Free certified professionals, we want to make your visit to our hospital the best it can be for you and your pet. Please answer a few questions so we can take both you and your pet’s preferences for the visit into consideration

Which high reward treat would your pet prefer?

Has your pet ever experienced a stressful or upsetting visit at a previous veterinary hospital?*

Yes
No

Does your pet exhibit stress during transport or car rides?*

Yes
No

Does your pet become stressed or anxious when introduced to new people and/or animals?*

Yes
No

Has your pet been prescribed a medication to help reduce fear, anxiety and/or stress during a veterinary hospital visit?*

Yes
No

Electronic Consent

Release of Medical Records

Pet Information

Fear Free Questionnaire

Emergency

Airvet

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