Streamline Exotic Pet & Avian New Patient Intake

A detailed new patient intake form for exotic and avian vets that captures husbandry, diet, environment, and symptoms before the first appointment.

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Exotic Pet & Avian Veterinary Clinic New Patient Intake & Husbandry History Form

Owner Name

· · ·

Email Address

· · ·

Phone Number

· · ·

Submit

This exotic pet and avian veterinary new patient intake form helps your clinic collect everything it needs before a bird, reptile, rabbit, or other exotic pet arrives for its first exam. Owners provide their contact details along with the pet's name, animal type, species, breed or morph, sex and reproductive status, approximate hatch date or birth date, and where the animal was acquired. A dedicated husbandry section asks about enclosure type and dimensions, location in the home, substrate, perches or hides, temperature and humidity ranges, UVB bulb age, and the heating, lighting, and monitoring equipment in use.

Built for exotic animal hospitals, avian specialists, and general practices that treat non-traditional species, the form also records current diet components, a typical day's feeding routine including brands, amounts, supplements, and water source, plus household and environmental exposures. The medical history and consent section wraps up with the reason for the visit and a detailed description of current symptoms, including when they started and any changes in appetite, droppings or urates, weight, breathing, activity, or shedding.

Because so many health problems in exotic pets trace back to husbandry and nutrition, having this information before the appointment helps veterinarians identify likely causes faster and make better use of exam time. Owners can complete the form online from any device, your front desk no longer has to transcribe paper forms, and every new patient visit starts with a complete, organized history. Customize the fields to fit your clinic's species list and workflow, then share the link or embed the form on your website in minutes.

3 Pages

20 Questions

~7min To complete

Free No credit card needed

Field types Dropdown ×4 Long Text ×4 Multiple Choice ×3 Short Text ×2 Full Name Email Phone Address Date termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Owner & Patient Information 10 questions

Owner & Patient Information

1 Owner Name * Full Name

2 Email Address * Email

3 Phone Number * Phone

4 Home Address * Address

5 Pet's Name * Short Text

6 Animal Type * Dropdown

7 Species / Breed / Morph (e.g., African Grey, Bearded Dragon, Holland Lop) * Short Text

8 Sex & Reproductive Status * Dropdown

9 Hatch Date or Date of Birth (approximate is fine) Date

10 Where Did You Acquire This Pet? * Dropdown

Page 2 Husbandry History 5 questions

Husbandry History

1 Describe Your Pet's Cage or Enclosure (type and dimensions, location in the home, substrate, perches or hides, temperature and humidity ranges, and UVB bulb age if applicable) * Long Text

2 Heating, Lighting & Monitoring Equipment Used * Multiple Choice

3 Current Diet Components * Multiple Choice

4 Describe a Typical Day's Diet (brands, approximate proportions or amounts, feeding frequency, treats, supplements, and water source) * Long Text

5 Household & Environmental Exposures * Multiple Choice

Page 3 Medical History & Consent 5 questions

Medical History & Consent

1 Reason for Visit * Dropdown

2 Describe Current Symptoms or Concerns (when they started and any changes in appetite, droppings or urates, weight, breathing, activity, or shedding) Long Text

3 Previous Illnesses, Surgeries & Current Medications (include your prior veterinarian's name so we can request records) Long Text

4 I confirm I am the owner or authorized agent of this pet and that the information provided is accurate. I authorize examination and treatment, understand that handling and restraint carry inherent risks for birds and exotic animals, and accept financial responsibility for all services, with payment due at the time of service. * termsandconditions

5 Owner or Authorized Agent Signature * Signature

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.