Exotics Reptile History Form Your First and Last Name * First Name Last Name Email * Phone * (###) ### #### Pet's Name * Species * Pet's Age * Gender * Male Female Unknown How do you know the gender of your reptile? * DNA Surgically Physical Traits Probe Ultrasound Not sure gender 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? * Select all that apply Aquarium Mesh Wire / Cage Wood Enclosure Pond Free Range Rack System Indoors Outdoors Specific Room How big is the enclosure? How often do you clean and with what product(s)? * What other reptiles live in the house? What style of habitat: * Select all that apply Terrestrial Aquatic Semi-Aquatic Arboreal Semi-Arboreal What type of cage furnishings do you have? * Select all that apply Natural Branches Fake Branches Foliage Real Plants Stones Dig Box Water Bowl Hide Box Other What is on the bottom of the enclosure? * Select all that apply Newspaper Corn Cob Kitty Litter Towels Tile Paper Towel Wood Shavings/Chip Rubber Mat Indoor / Outdoor Carpet Calci-Sand Play Sand Bare Gravel Dirt Moss Other What is the daytime temperature? * What is the Basking site temperature? * What is the night temperature? * Humidity percentage? * Thermostat? * Yes No Thermometer? * Yes No Hygrometer? * Yes No How do you heat the enclosure? * Select all that apply Light bulbs Heat cable Heat tape Under tank heaters Ceramic heat emitters Mercury bulbs Hot rock(s) Room heater Water heater How do you control the humidity? * Select all that apply Humidifier in the room Mister/Fogger Drip system Spraying None How is water offered? * Select all that apply Dish Tray Dropper / Mister Portion of the cage Aquatic Soaking How is water filtered? * Select all that apply In-Tank filter Bio-wheel Canister None How often do you change the water? * What strength UVB bulb do you have? * 2.0W 5.0W 10W Other How often do you replace it? * Does your pet get natural sunlight? Yes No What do you feed your pet? * How often do you feed? * How often does your pet defecate? * Do you supplement with: * Select all that apply Calcium Calcium with Phosphorus Calcium with D3 Multi-Vitamin How often do you use the calcium? What brand do you use? * Put N/A if you do not use any How often do you use the multi-vitamin? What brand do you use? * Put N/A if you do not use any Thank you for filling out our form. We appreciate this information ahead of time. We look forward to seeing you and your pet!~Como Park Animal Hospital * 24 Hour Care~
