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Home
About Us
Services
People
Species
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Forms
New Patient Form
Amphibian History Form
Avian History Form
Reptile History Form
Small Mammal History Form
Outpatient CT Referral Form
Nurturing Happiness
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Contact
Avian 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
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 sex was confirmed
*
Surgery
DNA
Lay Eggs
Other
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
What is the primary reason you have brought your bird here today?
*
When did the problem or signs begin?
*
Have any medications been given or treatments been attempted?
*
Have there been health problems in the past?
*
COLLECTION
Do you own other birds or pets? If so, please describe the number of animal and the species housed.
*
Have there been any recent introductions of new pets or birds?
*
Yes
No
If yes, when:
MM
DD
YYYY
Has the bird presented today had contact with other animals, particularly in the last 30 days?
*
Yes
No
ENVIRONMENT
What is the cage type?
*
What is the cage size?
*
The cage is made of?
*
List all cage furniture, toys, and accessories:
*
Describe the number and type of perches:
*
What cleaning methods are used?
*
What is the frequency of cleaning?
*
What is the temperature of the house and room where the bird lives?
*
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?
Have any pesticides, aerosol sprays, or chemicals been used in the immediate vicinity of the bird environment?
*
Yes
No
I don't know
Do you have electric or gas heat?
*
Electric
Gas
Both - Duel fuel
I don't know
Other
Is your bird exposed to any smoke (tobacco), essential oils, kitchen oils, or others?
*
Have there been any changes in the environment (new house, pet, people, cage location, etc)?
*
NUTRITION
What is the diet? (What is offered and what is eaten?) Include brand names, and be as specific as possible.
*
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?
*
MISCELLANEOUS
How often is the animal handled?
*
Is your bird flighted?
*
Yes
No
Is your bird exposed to direct sunlight?
Yes
No
Does your bird spend time outdoors?
*
Yes
No
If yes, how often and for how long?
Has your bird laid eggs?
*
Yes
No
Does your bird have any behavior or aggression issues?
*
Thank you for submitting your Avian History Form!
