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REPTILE MEDICAL INTAKE FORM
Owner's Name:
Patient's Name:
Patient Species:
Reason for Visit:
Additional Concerns:
Last Fecal Date:
Current Diet Including Any Supplements:
Where is Cage Located?
What is the Substrate (on the bottom) in the Cage?
What are the Temperature & Humidity of the Cage?
Do You Have a Warm & Cool Side in the Cage?
Yes
No
Do You Use a UVA/UVB Light?
Yes
No
Do You Change the Bulb Every 6 Months?
Yes
No
Is the Reptile Housed Alone?
Yes
No
Any Other Animals in the Home?
Eating/Drinking?
Urinating/Defecating?
Vomiting?
Any Noticeable Weight Loss?
Yes
No
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