Name: Veterinarian
Brand: Brook-Falls Veterinary Hospital & Exotic Care

For our Records

This is my current contact information.

My contact information has changed and I need to update my records

Bird's Name

Owner Name

First

Last

Select all that characterize your bird's personality:

Relaxed

Anxious

Playful

Fearful

Aggressive

Other…

Describe why you brought your bird to see us today:

Has your bird had any previous illnesses or treatments?

Previous Veterinarian:

Have you requested records to be sent to us?

Yes

Is your bird vaccinated?

Yes

How long have you owned this bird?

Where did you obtain this bird?

Describe anything you know about your bird's life before living with you:

List any other birds in the house:

How does your bird entertain itself?

Describe the diet that is offered: list brand names, quantities, proportions, and contents. What is eaten? What is found onthe bottom of the cage? Have appetite or dietary preferences changed?

List any supplements provided (e.g. vitamin/mineral powders/liquids, cuttlebone, grit).

Describe caging and perches in terms of sizes, construction materials, and location.

How often do you clean the cage, and cleaning products used

Do you allow this bird to fly?

Describe toys: how many, construction materials, destructibility, and rotation schedule.

List any other items in cages or on/around perches.

Describe bathing routine: how often, what is used, how does the bird respond?

Where does the bird sleep? How many uninterrupted dark/quiet hours per night?

Describe lighting in terms of intensity, source, and hours per day. Is the bird exposed to natural sunlight that has not been filtered through glass or plastic? If so, how often and for how long?

Any possible exposure to hazards including: metals, insecticides, plants, vapors, exhaust fumes, aerosolized particles, contaminants on handler’s skin or clothing (e.g. cigarette smoke residue, perfume, or cosmetics), garden chemicals, cleaners, bathing sprays, cooking vapors, contact irritants, potential allergens?

Has your bird been DNA sexed?

Does your bird have a microchip?

STATEMENT OF FINANCIAL RESPONSIBILITY

I am aware that I am responsible for all charges related to medical services that my pet receives at Brook-Falls Veterinary Hospital & Exotic Care. I understand that I will be asked to leave a deposit for medical services should my pet require a hospital stay. I understand that I must pay in full at the time medical services are completed. I have been advised that any charges revealed during post care audits will be invoiced in a timely manner and remain my financial responsibility.

Name

First

Last

Date

FEATHER PICKING HISTORY

What does the bird do with the feathers?

Does your bird seem itchy?

Does your bird scream or vocalize when picking?

Will your bird interrupt an activity (i.e. eating) to pick?

Does the picking correspond to a certain time of day?

Avian Medical History

How're We Doing?

Get In Touch

Brook-Falls Veterinary Hospital & Exotic Care