Reptile History FormPet NameAgeSpeciesBreedSex Female Male UnknownBackground InformationLength of time ownedWhere acquired?Please select oneBreederPet storeRescueOther locationWhere is your reptile housed? Indoors Outdoors BothDoes the reptile roam freely in the house? Yes NoAre there any other pets? Yes NoIf yes, please specify.Is your reptile housed by itself? Yes NoIf no, please specify.When did your reptile last shed?Any problems shedding?HusbandryDescribe your enclosure, including size, type of cage, position, etc. PLEASE BRING PICTURESWhat are the temperatures within the cage? If unknown, please leave blank.Cold Side (F°)Hot Side (°F)Basking Spot (F°)What is the relative humidity within the cage? if unknown, please leave blank.What type of lighting is used? What heat source(s) is used?What material/substrate is used on the bottom of the cage?How often is the cage/substrate cleaned?What type of disinfectant is used?Any recent changes in housing? Yes NoIf yes, please specify.DietPlease list the items included in the diet, brand and amount/frequency fed.If insects are fed, are they gut loaded before? Yes NoIf yes, please specify.Are there any supplements used? Yes NoIf yes, please specify.How is water offered? Frequency changed?Have there been recent changes to diet? Yes NoIf yes, please specify.Owner InformationName*Secondary Owner?* Yes NoStreet Address*Address Line 2City*State/Province/Region*Zip/Postal Code*Phone*Email*How did you hear about us?*Please select oneInternetYellow PagesSignAdPet StorePersonal ReferralPet ShowOtherHow did you hear about us?Referrer's Name:Vet HistoryPrevious Veterinarian or Veterinary ClinicDate of Most Recent Vet VisitXX/XX/20XXAny pre-existing conditions?Have you scheduled an appointment with us?* Yes (If yes, when is your appointment?) NoIf yes, when is your appointment?Submit Your Pet's Info
