Reptile's Name
Email *
Common or Scientific Species Name *
Date of Birth *
Age *
How long have you had this animal? *
Where did you obtain this animal? *
If yes, please give details *
When did your reptile last shed?
How often has your reptile been shedding
If yes, list number and species
Has your reptile had contact with any other reptile in the last 30 days? *
When was the last reptile added to your household? *
Cage size *
If other, please specify *
What decor and furnishings are present?
Details
Details
How often is the cage cleaned? *
What cleaning/disinfectant agent are used? *
If other, please specify *
Power of heating equipment? *
If yes, please explain
If yes, please explain
What is the model and manufacturer? *
When was the light last replaced? *
Please give details
Please give details
How many hours of light are provided each day? *
If yes, how many hours per day or per week?
If yes, what is the humidity level? *
What are the day time temperatures? Hottest area, basking area
What are the day time temperatures? Coolest area
What are the night time temperatures? Hottest area, basking area
What are the night time temperatures? Coolest area
Please give details
How often do you feed your animal?
Amount *
Amount and type per feed *
Please give details
Please give details
If yes, how much and how often? *
How often? *
How often is the water changed? *
Details
Have you noticed any changes in eating/drinking behavior? Please provide details.
Have you noticed any changes in droppings? (Fecal Material, Urine, Urates) Please provide details.
Any additional comments
What is the primary complaint or what signs you have noticed? *
How long have they been present? *
Details
Has any other animals or persons in the household had any illness within the last 30 days? *
