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Home Forms Amphibian History Form

Amphibian History Form

"*" indicates required fields

Pet's Name*

Owner's First Name*

Owner's Last Name*

Species*

Age*

Gender*

Male

Female

Unknown

How do you know the gender of your reptile*

DNA

Surgically

Physical Traits

Probe

Ultrasound

This amphibian is a*

Pet

Breeder

Is your pet*

Wild Caught

Domestically Bred

Imported

Where did you get your pet?*

Breeder

Pet Store

Friend/Family

Rescue

Found/Caught

Was your pet quarantined?*

Yes

No

If yes, how long and where?*

What type of enclosure*

Aquarium

Pond

Rack System

Indoors

Outdoors

How big is the enclosure*

How often do you clean?*

What other amphibians live in the house?*

What type of cage furnishings do you have*

Natural Branches

Fake Branches

Foliage

Real Plants

Stones

Dig Box

Water Bowl

Hide Box

Other

If Other, explain*

What is on the bottom of the enclosure?*

Towel

Tile

Paper Towel

Rubber Mat

Play Sand

Bare

Gravel

Dirt

Moss

Other

If Other, please explain*

What is the day time temperature*

Basking Site*

Night temperature*

Humidity*

Thermostat*

Yes

No

Thermometer*

Yes

No

Hygrometer*

Yes

No

How do you heat the enclosure?*

Light Bulbs

Heat Cable

Heat Tape

Under Tank Heaters

Ceramic Heat Emitters

Mercury Bulbs

Hot Rock

Room Heater

Water Heater

How much of the enclosure is aquatic?*

Fully

Half

Isolated Dish

None

How do you control the humidity?*

Humidifier in Room

Mister/Fogger

Drip System

Spraying

How is water offered?*

Dish

Tray

Dropper/Mister

Portion of Cage

Aquatic

Soaking

How is water filtered?*

In-Tank Filter

Bio-Wheel

Canister

None

How often is the water changed?*

What is the pH of the water?*

What type of water?*

Aged

Tap

Distilled

Bottled

What strength UVB bulb do you have?*

2.0

5.0

10.0

How often do you replace it?*

What brand of bulb do you have?*

Repti-Sun

Sun Glow

Other

If Other, please explain*

What do you feed your pet?*

How often do you feed?*

How often does your pet defecate?*

Do you use

Calcium

Calcium with Phosphorus

Calcium with D3

Multi-Vitamin

How often do you use the calcium?

How often do you use multi-vitamin?

Please take a photo of your enclosure and be sure to upload it, or email it to us at [email protected]

Max. file size: 50 MB.

If your pet has been seen anywhere previously, please include the name so we can obtain records ahead of time

Signature*

Date*

MM slash DD slash YYYY

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Phone

This field is for validation purposes and should be left unchanged.

Get in touch

(847) 821-6189

1101 S Milwaukee Ave Ste 102,
Vernon Hills, IL 60061

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Companion Vernon Hills

1101 S Milwaukee Ave Ste 102,
Vernon Hills, IL 60061

Home
About Us
Services
Resources
New Clients
- New Client Form
PetDesk
Contact Us

Make An Appointment

Request a Prescription

Business Hours

Mon

8:00am - 6:00pm

Tues

8:00am - 6:00pm

Wed

8:00am - 6:00pm

Thu

8:00am - 6:00pm

Fri

8:00am - 5:00pm

Sat

8:00am - 2:00pm

Sun

Closed

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