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Reptile & Amphibian 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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Reptile & Amphibiain 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 *

Date *

Pet Name *

Breed (Common Name) *

Color *

Age *

Birthday *

Sex *

Male
Neutered Male
Female
Spayed Female

About Your Pet

Your pet was obtained from: *

A breeder
A pet store
Other

If other, please specify:

How long have you owned this pet? *

Other pets in your household *

If yes, please specify:

Other reptiles in your household: *

Are reptiles housed?

Together
Singly

Where are other reptiles located?

Any recent additions of reptiles to the household?

How is your pet’s attitude: *

Happy/active/normal
Depressed/Lethargic
Other

If other, please specify:

How often is your pet handled? *

For how long? *

When was the last shed? *

Any trouble shedding? *

If yes, how so?

Husbandry

Type of enclosure:

Metal
Wood
Glass/Plastic
Other

If other, please describe:

Cage size

length X width X height

Location:

Cage furniture:

Substrate Type:

How often is it changed?

What type of disinfection is used to clean enclosure? *

Does your pet ever go outside? *

If yes, how does it go outside?

In a case
Loose

Type of lighting:

How often is the light changed:

Light cycle:

Heat Source:

Humidity Source:

Humidity Level:

Cage Temperature: (min & max)

Basking area:

Nutrition

How is your pet’s appetite: *

Normal
Other

If other, please describe:

Type of food:

Amount fed/frequency:

Last feeding (time and what fed)

Do you add vitamin or calcium supplements to the food?

If yes, how often?

What kind of vitamin or calcium supplements you add?

If insects are fed, are they gut loaded?

Yes
No
Unknown

Where do you feed your pet?

Water source:

Frequency changed:

Past Medical History/Problems

Please describe any past medical history or problems *

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? *

Name