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Reptile/ Amphibian History Form

Pet Owner's Name*

First

Last
Email*
Would you like an email copy of your submission?
- Yes
- No
Address*

Street Address

Address Line 2

City

State

ZIP Code
Phone*
Pet's Name*

First
Species
Age
Sex
- Male
- Female
- Unknown
Has your pet ever been bred?
- Yes
- No
How did you acquire your pet?
- Store
- Breeder
- Rescue
Is your pet
- Wild caught
- Captive bred
Date acquired:

MM slash DD slash YYYY
Age when acquired:
Do you have any other pets?
- Yes
- No
If yes, specify species and when acquired.
When was the last shed?
Any trouble shedding?
Do you soak or mist the animal? How often? Describe:
Housing
Is your pet kept
- Indoors
- Outdoors
- Both
Give details:
How and where is your reptile/amphibian housed?
Size of cage/tank:
What is on the bottom of the cage/tank?
Temperature: (Min/Max.)
Humidity:
Do you have thermometers and hygrometers?
- Yes
- No
If yes, where in the tank?
Heating elements:
- Heat Rocks
- Heat Pad
- Ceramic Heat Emitter
- Basking Light
Wattage:
Where are the heating elements located?
Type of UVA/UVB provided:
When was the UVB bulb last changed?
Light cycle (hours light/dark):
Heat cycle:
Cage furniture & where located:
How often is your pet handled?
- Daily
- Occassionally
- Never
Specifically how often?
Is your pet housed alone?
- Yes
- No
If no, explain:
How often is the cage cleaned?
Describe method of cleaning:
How often are the food/water dishes cleaned?
Describe method of cleaning:
Has your pet's environment changed recently?
- Yes
- No
If yes, describe
Diet
What specific types of foods are offered to your pet? What amount of each food type is offered?
How often is your pet fed?
Last feeding:
Do you gut-load your insect prey? With what foods? For how long before feeding to your pet?
Any supplements offered?
- Yes
- No
If yes, which brand and how often?
Any recent diet changes or new foods?
- Yes
- No
If yes, describe:
Aquatic/Semi-aquatic Species: (Fill out only if applies to your pet)
How often is the water changed?
What type of filtration is used in the tank?
What is the water temperature?
Is there a water heater?
How often do you perform water changes?
How much of the water do you change?
Do you feed in a separate area out of the tank?
Do you add any treatments to the water (e.g.: dechlorinator, salt, etc.)? Describe:
Reason for Today's Visit
What signs have you noticed that prompted today's visit?
When did these symptoms start?
Has your pet been sick previously?
- Yes
- No
If yes, describe:
Has your pet ever been seen by another veterinarian?
- Yes
- No
If yes, list when:
Is your pet currently on any medication?
- Yes
- No
If yes, describe:
Do you deworm your pet?
- Yes
- No
If yes, describe:
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Pet Owner Forms

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Hillsborough

649 Route 206
Hillsborough, NJ 08844

T: (908) 359–3161

F: (908) 359-6586

Mount Laurel

2051 Briggs Road
Mount Laurel, NJ 08054

T: (856) 429–4394

F: (856) 722-6709

Tinton Falls

197 Hance Avenue
Tinton Falls, NJ 07724

T: (732) 747-3636

F: (732) 747-6562

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Hillsborough

649 Route 206
Hillsborough, NJ 08844

Get Directions

Mount Laurel

2051 Briggs Road
Mount Laurel, NJ 08054

Get Directions

Tinton Falls

197 Hance Avenue
Tinton Falls, NJ 07724

Get Directions

Hillsborough

(908) 359–3161

Call

Mount Laurel

(856) 429–4394

Call

Tinton Falls

(732) 747-3636

Call