Avian History Form Owner’s Name:Pet’s Name:Today’s Date Home Phone:Cell Phone:Work Phone:Which phone number should we use to contact you today?HomeCellWorkOther:Other:If appropriate, would you prefer us to contact you via text message?YesNo[Valid cell number]Email Address: Do you have Pet Insurance?YesNoIf “Yes”: Which provider is your policy with?How long have you owned this bird?From what source did you acquire it?Pet ShopBreederOtherOther:What do you feed your bird? (Please be specific.)Do you give any supplements?YesNoIf “Yes” Vitamins Minerals Does your bird appear to have any problems?YesNoIf “Yes”: What symptoms have you noticed?When did these symptoms first appear?Has your bird had any previous illnesses?YesNoIf “Yes”: Please describe:Has your bird received any medication(s) recently?YesNoIf “Yes”: Please list them:Have there been any recent changes in the bird's environment?YesNoHas your bird's appetite changed in any way?YesNoHas there been any change in the color or consistency of the bird's droppings?YesNoHave you noticed any signs of respiratory problems?YesNoHave you noticed any regurgitation?YesNoDoes your bird have any cage mates?YesNoIf “Yes”: Are the cage mates showing any signs of illness?YesNoHave any new birds been added to your aviary or household?YesNoHas your bird been exposed to any other birds including wild birds? (e.g. boarding, pet shop, etc.)YesNoOther comments?Diagnostics and Treatment Consent I hereby authorize Suffield Veterinary Hospital to perform professional services that are, in their opinion, advised for treatment and maintenance of my pet’s health and wellbeing.I also authorize the following, if necessary, to be performed: Blood work X-Rays Sedation/Anesthesia Surgery Website and Social Media Release I hereby grant Suffield Veterinary Hospital permission to use the likeness of my pets (s), should they so choose, in a photograph, video, or other digital reproduction in all of its publications, including website and social media entries, without payment, compensation, or any other consideration. I understand and agree that these materials will become the sole property of Suffield Veterinary Hospital.In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my pet’s likeness appears. Yes No Payment for Products, Medications and Services Rendered I understand that the invoice resulting from my pet’s admission to Suffield Veterinary Hospital is to be paid in full at the time my pet is discharged from Suffield Veterinary Hospital. I will satisfy payment via the following method: Cash Check Visa/MasterCard//Discover/American Express CareCredit I am the owner or agent of the aforementioned pet, am at least 18 years of age, and am competent to contract in my own name. I have read this document in its entirety before signing below and I fully understand all the content in this document and its meaning. I fully understand the impact of signing this release.SignaturePRINTED NAME:Date
