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Avian History Form

Save time during your next appointment. Complete your required forms online from any device at any time before your visit.

Avian History Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Name *

First

Last

Phone *

Email *

Animal Details

Avian name of identification *

Common or scientific species name: *

Date of birth *

Age *

Sex *

Male
Female
Neutered/spay
Unknown

Determined by: *

DNA
Endoscopy
Visual
Other

Please specify:

Origin *

Captive bred
wild caught import
Unknown

How long have you had this bird?

From where did you obtain this bird?

Does this bird have a reproductive history? *

Yes
No

If yes, please give details:

When did your bird last molt? *

How often has your bird been molting?

Is your bird vaccinated? *

Yes
No

Please give details:

Does your bird get wing trimmed? *

Yes
No

If yes, please give details:

Do you have other birds or pets? *

Yes
No

If yes, please give details:

Have you or your bird had any contact with other birds in the last 30 days? *

Yes
No

If yes, please give details:

When was the last bird added to your collection? *

Reason For Presentation Today

What is the primary complaint or what signs have you noticed? How long have these problems been present?

What health problems has your bird had previously?

Has your bird received any treatment in the last 30 days? *

Yes
No

If yes, please give details (What was used, dosage, how often, duration):

Have you noticed any change in your birds behavior? *

Yes
No

If yes, please give details:

Have any other animals or persons in the household had any illness in the last 30 days? *

Diet

How often do you feed your animal?

Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume): *

Seed mixtures
Pellets
Fruits and/or vegetables
Meat
Treats
Other

Please specify:

Amount

Type/Brand

Meat type: *

Freshly killed
Frozen/thawed
Live prey

Do you use any nutrition supplements? *

Yes
No

If yes, what, how much and how often?

What water supply do you provide? *

Tap water
Bottled water
Rain/river water

How often is water provided *

Bowl
Dripper system
Spray

How often

How often is the water changed

Do you use any water supplements? *

Yes
No

If yes, please give details:

Have you noticed any changes in feeding or drinking behavior? *

Yes
No

If yes, please give details:

Have you noticed any changes in droppings (fecal material, urine, and urates)? *

Yes
No

If yes, please give details:

Cage Environment

Where is the cage located? *

Inside
Outside

Please give details:

What is the cage made of? *

Cage size? *

What kind of bedding is used? *

What decor and furnishings are present? *

Nest box
Perches
Swings
Toys
Other

Please give details:

Are bathing/spraying faciilites provided? *

Yes
No

If yes, please provide details:

How often is the cage cleaned? *

What cleaning/disinfectant agents are used? *

What percentage of time does your bird spend inside of its cage? *

What percentage of time does your bird spend outside of its cage? *

Is the animal supervised when out of the cage? *

Yes
No

Please give details:

Does your bird have regular exposure to sunlight? *

Yes
No

Frequency and length of time: *

Is your bird exposed to full spectrum (UVA and UVB) lighting? *

Yes
No

Brand?

What is your bird's light/dark cycle? *

Does anyone in the household smoke? *

Yes
No

Do you use any aerosolized products? *

Yes
No

Have there been changes in the birds environment in the last 3 months? *

Yes
No

If yes, please give details:

Ready to Visit?

We Know Pets Are Family

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Questions?

Get in touch! We look forward to hearing from you.

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Location

2533A Vandalia St.
Suite B
Collinsville, IL 62234

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Contact Information

Email: hello@villagevetpet.com
Phone: 618-750-PETS (7387)

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Hours

Monday – Friday: 8:30 am – 5:30 pm

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First

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Email *

Phone

How can we help you? *

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We Proudly Serve the Pets of the Collinsville, IL Area, and Surrounding Towns in the MetroEast Area

Maryville, IL
Glen Carbon, IL
Edwardsville, IL
Troy, IL
Alton, IL
Godfrey, IL

O'Fallon, IL
Marine, IL
St. Jacob, IL
Highland, IL
MetroEast St. Louis

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