Reptile Intake Form

Owner Information:

Date of Your Pet's Appointment*

Time of Your Pet's Appointment*

: HH

MM

Location of Your Pet's Appointment*

We have two location in Brockville. If you are unsure which location your pet's appointment has been scheduled at, please let us know.

First Name:*

Last Name:*

Address:*

Phone Number*

Email Address:

Best Method of Contact:*

Phone
Text
Email

Pet Information:

Pet's Name:*

Species

Pet's Age:*

Birthday (if known, if unknown “gotcha” day):*

Sex (if known):*

Male
Female
Unknown

When did you acquire this pet?

Any other animals in your house/ cage mates?*

Yes
No

If Yes, please specify:

Terrarium:

Dimensions:

Bulb Types:

House Temperature:

Hot Temperature:

Cold Temperature:

Hours of Light:

Humidity:

Substrate Type:

Cleaning Schedule/Products (please list):

Diet

Diet Type (select all that apply):*

Select All
Insects
Rodents (if applicable)
Vegetables
Fruit
Supplements

Diet (list items and % of diet/how often):

Feeding Location:*

Reason for Appointment

What is the reason for this appointment?*

How long ago did it start?

Any other pets affected?

Do you have other concerns?

Monday	8:00am – 8:00pm
Tuesday	8:00am – 8:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 5:00pm
Saturday	8:00am – 4:00pm
Sunday	Closed