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Home Forms Fish History Form

Fish History Form

"*" indicates required fields

Pet's Name*

Owner's First Name*

Owner's Last Name*

Species*

Breed*

Age*

Color*

Gender*

Male

Female

Unknown

How as pet sexed*

Physical Traits

Ultrasound

Unsure

Other

If other, please explain*

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

Indoors

Outdoors

Fresh Water

Salt Water

Brackish

Other

If other, please explain*

How big is the enclosure?*

How often do you clean?*

What other animals/plants/coral live in the enclosure?*

What type of cage furnishings do you have?*

Natural Branches

Fake Branches

Real Plants

Plastic Plants

Silk Plants

Hides

Rocks

Other

If other, please explain*

What is on the bottom of the enclosure?*

Bare

Sand

Large Gravel

Small Gravel

River Rock

Silt

Other

If other, please explain*

Do you have supplemental heat?*

Yes

No

What type of heater?*

Do you have supplemental cooling?*

Yes

No

What type of cooler?*

What is the temperature of the water?*

What is the light cycle?*

How often is the water changed?*

How much water is changed?*

1/4

1/2

1/3

Full

How often is the water chemistry tested?*

Brand of water test kit*

What type of filter?*

Canister

Bio Wheel

Power Filter

Under Gravel

Other

If other, please explain*

How often is the filter media cleaned?*

How often is the filter media changed?*

Do you have an aeration system?*

Filter

Aerator Stone

None

Other

If other, please explain*

What type of lighting does your tank receive?*

None

Fluorescent

UVB

In the case of pond fish, do you bring the min during the winter?

Yes

No

What is the pH of the water?*

What type of water?*

Dechlorinated

Aged

Distilled

Tap

What additives do you put in the water?*

Signature*

Date*

MM slash DD slash YYYY

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 of the facility so we can obtain records ahead of time

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(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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