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Home
About Us
Services
People
Species
Facility
Forms
New Patient Form
Amphibian History Form
Avian History Form
Reptile History Form
Small Mammal History Form
Outpatient CT Referral Form
Nurturing Happiness
Online Pharmacy
Contact
Amphibian History Form
Thank you for choosing Lucks Lane Veterinary Clinic. Please fill out the form below and our Front Desk team will reach out with any next steps.
Owner Name
*
First Name
Last Name
Email
Pet's Name or Identification
*
Species
*
Age
*
Unknown
Less than 1 year
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
20+
Sex of Pet
*
Male
Female
Unknown
Origin
*
Wild Caught
Captive Bred
Unknown
How long have you owned?
*
Less than 1 year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
More than 20 years
Unknown
Any previous owners?
*
Yes
No
MEDICAL INFORMATION
What is the primary reason you have brought your amphibian here today?
*
When did the problem or signs begin?
*
How long has the problem or signs lasted? Have the problems or signs changed in any way?
*
Have any medications been given or treatments been attempted?
*
Have there been health problems in the past?
*
COLLECTION
Do you own other amphibians? If so, please describe the number of animals and the species housed.
*
Have there been any recent introductions of new pets or amphibians?
*
Yes
No
If yes, when:
MM
DD
YYYY
Has the amphibian presented today had contact with other animals, particularly in the last 30 days?
*
Yes
No
ENVIRONMENT
What is the cage type?
*
Terrestrial (land-dwelling)
Arboreal (tall, climbing)
Semi-Aquatic
Aquatic
Other
What is the cage size?
*
Cage material:
*
Glass
Plastic / Fiberglass
Metal
Wood
Other
How is ventilation provided?
*
What is the cage substrate (what is used to line the bottom of the cage)?
*
List all cage furniture and accessories:
*
What cleaning methods are used?
*
What is the frequency of cleaning?
*
What is the temperature gradient or range?
*
Are there heat sources?
*
What is the humidity?
*
What light sources are provided?
*
Is full-spectrum UV-B or UV-A lighting used?
*
Yes
No
How old are the full-spectrum lights? How often are they changed?
How many hours of light are provided daily? How many hours of dark per day?
*
How are the heat and light source(s) placed relative to the termometers?
*
Have any pesticides, aerosol sprays, or chemicals been used in the immediate vicinity of the reptile environment?
*
Yes
No
I don't know
WATER QUALITY
What is the water source?
*
City Water or Local Well
Bottled Water
Distilled Water
Reverse-osmosis
For city or well water, how are chloride or chloramines removed?
Aeration (aging)
Agitation
Activated charcoal filtration
Chemical treatments
What is the frequency of water changes?
*
How often are filters cleaned or changed?
*
Is the water heated?
*
Yes
No
If yes, what is the water temperature range?
*
Is any type of water testing done?
*
Yes
No
If yes, please provide the latest results here:
Ph
Nitrite
Nitrate
Dissolved O2
Ammonia
Alkalinity
Hardness
NUTRITION
What is the diet? (What is offered and what is eaten?) Include brand names, and be as specific as possible.
*
How long are prey items kept with the animal?
*
Where are the food items obtained?
*
Please describe the type and frequency of supplimentation.
*
What is the frequency and timing of feeding?
*
When did the animal last eat?
*
Where is food purchased?
*
If live prey is offered, what care is provided?
For non-aquatic species, how is water provided?
MISCELLANEOUS
How often is the animal handled?
*
Has the animal gone through brumation (hibernation)?
*
Yes
No
I don't know
What breeding practices are utilized?
Have there been recent changes in diet, environment, or husbandry?
*
Thank you!
