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Rabbit & Rodent 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(Required)

First Last

Email(Required)

Today's Date(Required)

MM slash DD slash YYYY

Patient Information

Species(Required)

Sex(Required)

Male

Female

Unknown

Spayed/Neutered?(Required)

Yes

Date of Birth(Required)

Date Acquired(Required)

Source (pet store, breeder, previous owner, etc.)(Required)

Number of previous owners (other than breeder, store)(Required)

What states and countries has your pet lived in?(Required)

Environment

Is the animal kept indoors or outdoors?(Required)

Indoors

Outdoors

Describe the cage enclosure - type, size, objects in the cage (dust baths, toys, etc.)(Required)

What material is used to line the bottom of the cage/litter pan?(Required)

Is the animal kept in a cage with other animals?(Required)

Yes

If yes, how many cage-mates are there? What sex are the cage-mates? Are the cage-mates spayed/neutered?(Required)

Please list all other pets in the household(Required)

Have there been any new pets (within the past six months) placed in this animal's cage?(Required)

Yes

How much time does your pet spend outside of the cage?(Required)

Is your pet supervised when it is out of the cage?(Required)

At all times

Sometimes

Does your pet chew on carpet or other objects/materials when outside of the cage?(Required)

Yes

List recent changes in the environment, if any

Diet

What amount of your pet's diet consists of the following (please describe what the animal actually eats, rather than what is offered)

Amount of hay (timothy, alfalfa, etc.)(Required)

Amount of pellets (timothy, alfalfa, etc.)(Required)

Amount of seeds (type/brand)(Required)

Amount of vegetables (types)(Required)

Amount of fruits (types)(Required)

Other (list types and amount)(Required)

How often do you change your pet's food?(Required)

What (if any) treats do you give your pet (brand and amount)?(Required)

Do you supplement your pet with any vitamins? Is the food or water supplemented with vitamins? Brand and frequency?(Required)

Please describe any recent change to your pet's diet(Required)

Reproduction

Has this pet been bred before?(Required)

Yes

If yes, how many times?(Required)

When was it last bred?(Required)

What was the size of all previous litter(s)? Was the litter healthy?(Required)

Do you plan on breeding this pet in the future?(Required)

Yes

Is your pet here for a:(Required)

Well pet checkup

Sick visit

If your pet is sick, please describe the signs and how long your bird has been showing these signs(Required)

Is your pet's activity level normal?(Required)

Yes

Is your pet's appetite normal?(Required)

Yes

Have you noticed any of the following:

Weight loss

Weight gain

Discharge from the eyes or nose

Increased breathing rate or effort

A change in droppings

Increased thirst

Decreased thirst

Weakness

Has your pet had any previous conditions operations, or problems (including dental or gastrointestinal problems)?(Required)

Is your pet currently on any medications?(Required)

Yes

If yes, please specify(Required)

Has your pet been on any medications recently?(Required)

Yes

If yes, please specify(Required)

Is there anything else you would like done today?

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Comments

This field is for validation purposes and should be left unchanged.

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Hoboken Vets Animal Clinic proudly serves the pets of Hoboken, Jersey City, Union City, Edgewater, Weehawken, and beyond. We look forward to your next visit!

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Address

1160 Maxwell Ln, Hoboken, NJ 07030

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contact

P: 201-559-5133 (Call or Text)
E: info@hobokenvets.com

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Hours

Monday-Friday: 8am-7pm
Saturday: 9am-5pm
Sunday: Closed

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