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Chinchilla New Patient Form

"*" indicates required fields

Client Information

Name*

First

Last

Phone*

History

Pet's Name*

Species*

Age*

Sex*

Male

Female

Unknown

Where did you get your pet?*

When did you get your pet?*

Has your pet been to a vet before?*

Yes

No

Where?

Any prior medical concerns?

Do you have any medical records?

Is your pet on any medications?

Habitat

What kind of habitat do they live in?*

What size is the habitat?*

Is the habitat multilevel?*

What bedding is in the habitat?*

How often is it cleaned?*

What is it cleaned with?*

Any hides/furniture?*

Cooling stone?*

Is your pet litter box trained?*

Yes

No

What kind of litter?

How often is it cleaned?

Grooming

Is your pet given dust baths?*

Yes

No

How often?

Brand of dust?

Diet

Hay type and brand?*

Amount and frequency?*

Pellet type and brand?*

Amount and frequency?*

Are veggies and fruits offered?*

Yes

No

Types?

Amount and frequency?

Treat type and brand?*

Amount and frequency?*

What water source is offered?*

How often is it cleaned?*

Are any supplements offered?*

Yes

No

Type, amount, and frequency

How is it provided?

Enrichment

Does your pet spend time outside of their habitat?*

Yes

No

How often and for how long?

Inside or outside?

Are they ever allowed to roam unsupervised?

Does your pet have access to toys?*

Yes

No

What kind?

How often are they changed/cleaned?

Does your pet interact with any other animals?*

Yes

No

What kind?

Is your pet routinely handled?*

Yes

No

By who?

Signature*

Date*

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Email

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