"*" indicates required fields

Client Information

Name*

First

Last

Phone*

History

Pet's Name*

Species*

Age*

Sex*

Male

Female

Unknown

How do you know your pet's gender?*

Where did you get your pet?*

When did you get your pet?*

Has your pet been to a vet before?*

Yes

Where?

Any prior medical concerns?

Is your pet on any medications?*

Yes

Please list medications

Habitat

What kind of habitat do they live in?*

Where in the home is it located?*

Indoor or outdoor?*

What size is the habitat?*

What is the top covered with?*

Is there any kind of substrate?*

How often is it cleaned, and with what?*

What is in the enclosure with your pet?*

Hides. Plants (real and artificial), furniture or decorations

What type of light source(s) are used?*

Do you provide UVA?*

Do you provide UVB?*

How often is it replaced?*

Where is lighting positioned?*

What time is it turned on/off?*

What type of heat source is used?*

Is there a lamp?*

Yes

Does it also provide light?

How often is it replaced?

Where is it positioned?

Is there an under-tank heater?*

Yes

What barrier is between the heater and the pet?

Is the heat source ever turned off for any amount of time?*

What is the typical enclosure temperature?*

Is there a range (cool zone / hot zone)?*

How is the temperature monitored?*

What is the typical humidity in the enclosure?*

How is it maintained?*

How is it monitored?*

Is it adjusted when pet is shedding?*

Is a water bowl provided?*

Yes

Size?

How often is it cleaned, and with what?

If no water bowl available, what water source is available?

Is your pet regularly soaked?*

Yes

How often and how long?

Is an area for soaking provided in the enclosure?

Diet

What is being fed?*

Hay / Grasses

Veggies

Pellets / Commercial Diet

Other

Type, amound and frequency

Any supplements? (Ex: Calcium, multivitamin, vitamin A,etc)*

Yes

Type, amount and frequency of each?

How is it provided?

Enrichment

Does your pet spend time outside of their habitat?*

Yes

How often and for how long?

Inside or outside?

Are they ever allowed to roam unsupervised?

Does your pet interact with any other animals? What kind?*

Is your pet routinely handled and by who?*

Signature*

Date*

Name

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Tortoise New Patient Form

Client Information

History

Habitat

Diet

Enrichment