Avian and Small Mammal History Form Owner’s Name:Pet’s Name:Today’s Date MM slash DD slash YYYY Home Phone:Cell Phone:Work Phone:Which phone number should we use to contact you today? Home Cell Work Other: Other:If appropriate, would you prefer us to contact you via text message? Yes No [Valid cell number]Email Address: Do you have Pet Insurance? Yes No If “Yes”: Which provider is your policy with?How long have you owned this pet?From what source did you acquire it? Pet Shop Breeder Other Other:What do you feed your pet? (Please be specific.)Do you give any supplements? Yes No If “Yes” Vitamins Minerals Does your pet appear to have any problems? Yes No If “Yes”: What symptoms have you noticed?When did these symptoms first appear?Has your pet had any previous illnesses? Yes No If “Yes”: Please describe:Has your pet received any medication(s) recently? Yes No If “Yes”: Please list them:Have there been any recent changes in the pet's environment? Yes No Has your pet's appetite changed in any way? Yes No Has there been any change in the color or consistency of the pet's droppings? Yes No Have you noticed any signs of respiratory problems? Yes No Have you noticed any regurgitation? Yes No Does your pet have any cage mates? Yes No If “Yes”: Are the cage mates showing any signs of illness? Yes No Have any new pets been added to your aviary or household? Yes No BirdsHave you noticed any regurgitation? Yes No Has your bird been exposed to any other birds including wild birds? (e.g. boarding, pet shop, etc.) Yes No Other comments?Small MammalsDoes your pet have any allergies or vaccine reactions? Yes No If yes, what are they?Do you use any flea/tick preventative? Yes No What kind?Date last administeredDiagnostics 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 MM slash DD slash YYYY
