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New Patient Questionnaire - Exotic Mammals

If your exotic companion mammal is a new patient at Carolina Veterinary Specialists please fill out our New Exotic Mammal Patient form using one of the options below.

Please note that appointments must be made by phone, so please call us us if you want to book an appointment.

Client's first name *

Client's last name *

Client's date of birth (primary client must be 18 or older) *

Primary email address *

Primary phone number *

Please indicate if this number is a cell phone, home, or work number. *

Is it okay to text you at this number or leave voice mail messages? *

Additional client or authorized agent

Phone number for additional client or authorized agent

What is the best way to reach you? *

Mailing address *

Is there anything you would like us to know about you or anyone else visiting with you, so that we can provide you with reasonable accommodations during your visit and make your visit with us as comfortable as possible? You can include things such as hearing or vision impairment, mobility impairment, mental health challenges, language barriers, etc.

About Your Pet

Pet's name *

Date of birth (or age) *

Species *

Breed and color pattern (if known) *

Sex *

Date your pet was obtained *

Place your pet was obtained *

Housing and Environment

Please describe your pet’s housing here. Please include materials and approximate dimensions of their enclosure and any provided exercise pens, location of your pet’s enclosure in the home, cage liners, wheels, dust baths, and litter boxes and litter used. *

Is your pet allowed to roam free in the home or taken outdoors? If so, please describe. *

Diet and Supplements

Please describe the diet for your pet here. Please include brand names for any commercially produced diets. Please describe the amount offered of each food item if the quantity of the food item is measured or otherwise limited, or state if it is offered at all times. *

Please describe any supplements you provide for your pet here, including vitamins, mineral blocks, and others. *

Please describe any treats you provide for your pet here. *

Please describe the source of drinking water and if water is provided in a bottle or a bowl (or both).

Environment and Enrichment

Are there any cage mates? If so, please describe. Are the cage mates healthy? *

Are there other pets in the home? If yes, please describe. *

If you provide enrichment items and activities for your pet, please describe here.

Behavior and Personality

Please describe your pet’s personality.

Are there any current or previous behavior concerns? If so, please describe.

Medical History

Has your pet had previous preventative health care visits to a veterinarian? If so, please describe. *

Has your pet ever been seen in the past for a medical or behavioral problem by a veterinarian? If so, please describe. *

Rabbits only – Please provide the date of the last RHDV2 vaccine (if any).

Ferrets only – Please provide the date of the last rabies vaccination and canine distemper vaccination (if known).

Ferrets only – Is your ferret currently on heartworm preventative? If so, please describe.

Previous medical records can be uploaded below or emailed to us at exotics@carolinavet.com. Will you be providing or requesting previous medical records for us? *

If "No," do we have permission to contact your previous veterinary hospital(s) to obtain medical records?

If "Yes," please provide the name(s) of previous veterinary hospital(s) we can contact to obtain medical records

Reason for Visit

What is the reason for your visit? *

If here for a medical or behavioral concern, please describe. Please include when the problem was first noticed, how it has changed, treatments used, and response to treatment.

If your pet is currently on any medications or supplemental therapies, please provide details here, including any adverse drug reactions.

Other

Are there any special requests for handling your pet today?

Please describe any additional questions or concerns you may have about your pet.

If your pet is a rabbit less than six (6) months of age, please bring a recent fecal (stool) sample with you from home, in a sealed container, so that we are able to screen your rabbit for intestinal parasites (mainly coccidia). Samples can be kept refrigerated for up to three days.

Upload Files or Images

You can upload document and image files here, including previous medical records, notes, radiographs (X-rays) and ultrasound images. We would love to see photos of your pet and where they live!

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New Patient Questionnaire - Exotic Mammals

About Your Pet

Housing and Environment

Diet and Supplements

Environment and Enrichment

Behavior and Personality

Medical History

Reason for Visit

Other

Upload Files or Images

Caring for Pets in Huntersville