Avian History Form

Name: Santa Rosa Veterinary Hospital
Address: 2002 4th St, Santa Rosa, CA, 95404, United States
Telephone: 707-544-1313
Price range: $

Please fill out the following form before your scheduled appointment with us!

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Avian History Form

Thank you for choosing Santa Rosa Veterinary Hospital. Please fill out the following form as thoroughly as possible so we can get to know your pet before their appointment with us. If you are in need of immediate assistance, please contact us at 707-544-1313.

Owner's Name *

First

Last

Phone *

Email *

Bird's Name *

Breed *

Sex *

Male
Female
Unknown

How was the sex identified? *

DNA Test
Other

If other, please describe:

Identification

Tattoo
Microchip
Band

Tattoo

Microchip

Band

Your pet was acquired from? *

A breeder
A pet store
Other

If other, please describe:

Length time Owned? *

Fecal output *

Normal
Diarrhea
None

Urine output/Urates *

Normal
Abnormal

Any other pets? *

If yes, please specify:

Other pets housed:

Separately
Together

Any recent addition of birds to household?

Are any other birds sick or have died?

If yes, please describe:

How often is pet handled? *

Daily
Occasionally
Never

Has bird ever laid any eggs? *

When was the last clutch?

Number of eggs?

Husbandry

Type of enclosure *

Cage
Aviary
Other

If other, please describe:

Size of enclosure:

Location of enclosure:

Bird allowed to be free in house? *

If yes, how many hours a day?

Unsupervised?

Bird taken outdoors? *

If yes, please describe:

List type of perches available: *

List toys/enrichment/furniture available to the bird: *

What do you use on the bottom of the cage? *

Does the cage have a grate? *

Can bird reach through it?

Frequency of cage cleaning: *

What type of disinfection used? *

Method/Frequency of cleaning food/water receptacles: *

Smokers in the house? *

Wood fireplace in home? *

Nutrition

Diet *

Pelleted food
Seeds
Table foods
Other

Pelleted food brand:

Seed(s) Type:

What Food:

If other, please describe:

Describe diet or eating habits: *

Recently added food or dietary changes *

How is appetite? *

Water source: *

Frequency changed

Medical History

Past medical history/problems: *

What tests has the bird been given?(Check all that apply) *

Psittacosis
Psittacine beak and feather disease
Polyomavirus
Parasites
Blood Tests
Culture
Other

If other, please describe:

List all vaccines the bird has been given and the date it was given:

Any current medications? Please specify route, frequency and amount given: *

Ready for a visit?

We proudly serve the pets of Santa Rosa, Cotati, Rohnert Park, Sebastopol, Petaluma, and beyond. We look forward to seeing you and your pet—request an appointment today! And with our new app, you may request appointments 24/7, receive automatic reminders, save notes, photos, and much more.

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Have a question?

Get in touch! Complete our online form, and a member of our team will be in touch with you shortly.

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Where to Find Us

2002 4th St
Santa Rosa, CA 95404

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Our Hours

Mon–Fri: 8am – 12pm & 1pm – 5:30pm
(Closed during lunch time)
Sat–Sun: Closed

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Get in Touch

707-544-1313
707-544-0417 (fax)
[email protected]

Name *

First

Last

Email *

Phone

How can we help you? *

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