CAH Downloadable Forms - Centennial Animal Hospital (MB)

Owner's Name *

Phone Number *

Email *

Pet's Name *

Birthday *

Sex *

Species *

Breed *

Tank type (glass, wood, etc.) *

Tank Size (W x L x H) *

Tank Temperature - Basking Side *

Tank Temperature - Hot Side *

Tank Temperature - Cool Side *

Tank Temperature - Night Time *

How is heat provided? (ie. lights, under tank heater) *

Is a UV light used? Provide brand name and frequency it is changed.

Humidity (are there more and less humid areas)? *

Substrate type *

Water dish provided: *

Is water treated, bottled or tap? *

Size of dish? *

Please list all food items offered (if commercial, list brand) *

What % of each food makes up diet (ex. 20% crickets, 50% pellets, 30% veggies). If insects are used, are they gut loaded & with what? *

Please list what supplements are used and how often *

Include brand & type (ie. Rep-cal calcium with D3)

Does your pet get bathed? *

If yes, how often & in what (ie. bath tub, rubbermaid)? *

Does your pet get outdoors? If yes, how often? *

When was the last shed? *

How often does your pet shed? *

How often is a full tank cleaning performed? *

WATER-BASED PETS

Filter type & capacity

Substrate (ie. rocks, sand, etc)

Ph Level:

Ammonia Levels:

How frequently is the water changed?

Is the water treated?

Are there live plants? If yes, what type?

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

New Patient Form - Exotics

WATER-BASED PETS

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