Skip to content
Facebook-f
Instagram
Youtube
Online Store
Contact Us
Download Our App
Online Store
Contact Us
Download Our App
Services
Wellness and Life Stage Exams
Pet Dental
Urgent & Emergency Care
Surgery
Pet Boarding
Ultrasound
Digital Radiography
View All Services
Wildlife
Pet Owners
Online Forms
Apply For Care Credit
Online Store
RX Refill
Download Our App
Education
About Us
Meet Our Team
Online Store
Contact Us
Download Our App
Menu
Services
Wellness and Life Stage Exams
Pet Dental
Urgent & Emergency Care
Surgery
Pet Boarding
Ultrasound
Digital Radiography
View All Services
Wildlife
Pet Owners
Online Forms
Apply For Care Credit
Online Store
RX Refill
Download Our App
Education
About Us
Meet Our Team
Online Store
Contact Us
Download Our App
24/7 Emergency Care
Emergency & Urgent Care
Book an Appointment
Amphibian Questionnaire
Patient Information
Pet Name
(Required)
Species
(Required)
Approximate Age
(Required)
Sex
(Required)
Male
Female
Unknown
How long have you owned this pet?
(Required)
Where did you get this pet?
(Required)
Medical History
Has your pet been to a vet before?
(Required)
Yes
No
Has your pet been dewormed before?
Please note any previously diagnosed medical concerns for your pet below
Husbandry / Care
Please bring a picture of your pet's enclosure to your appointment
Is your pet housed alone or with other animals?
Alone
With Other Animals
Do you handle your pet?
Yes
No
Does your per live indoors or outdoors?
Indoors
Outdoors
Has both indoor and outdoor housing
Describe the pet’s housing set-up. Include approximate size, construction materials, and a diagram if applicable.
(You are welcome to bring a picture or drawing to your appointment if that is easier)
Lighting
What type of lighting does the enclosure have (UVB, heat, infrared, other)?
UVB
Heat
Infrared
Other
Does your pet have access to a UVB bulb?
Yes
No
How often is the UVB bulb changed (as needed, yearly, every 6 months)?
Every 6 months
Yearly
As needed
Other
How many hours a day are the lights on in your pet’s enclosure?
Heating / Humidity
What type of heater is used (submersible, heat pad, heat bulb)?
Submersible
Heat pad
Heat bulb
Other
What is the water temperature?
What is the temperature in the hottest part of the enclosure?
What is the temperature in the coolest part of the enclosure?
Are the heating devices attached to a thermostat?
Yes, heating devices attached to thermostat
No, heating devices NOT attached to thermostat
Other
Other
What type of thermometer is used?
What is the humidity in the environment?
How is humidity maintained? (fogger, spray bottle, humid hide, etc)
Fogger
Spray bottle
Humid hide
Other
Environment
What substrate is used (Glass bottom, Gravel, Soil, Stones, etc)?
Glass bottom
Gravel
Soil
Stones
Other
How frequently is the environment cleaned?
What cleaners are used?
Does your pet have access to a moist/humid hide area?
Yes
No
Feeding
List ALL types of food items given including quantity and frequency (live vs freeze dried)
Do you gut-load insects?
Yes
No
N/A
Do you feed live or frozen-thawed prey?
Live
Frozen/thawed
N/A
Please list any supplements/vitamins and how they are administered (in a bowl, sprinkled over food, etc):
Water Quality
Do you perform complete/partial water changes?
Complete water changes
Partial water changes
Both
How often do you perform water changes?
How do you treat the water before adding it?
What type of water do you use (tap, bottled, RO, distilled)?
Tap
Bottled
RO
Distilled
Other
Any other comments?
CAPTCHA
Emergency & Urgent Care
Emergency & Urgent Care
Book an Appointment
Skip to content
Open toolbar
Accessibility Tools
Accessibility Tools
Increase Text
Increase Text
Decrease Text
Decrease Text
Grayscale
Grayscale
High Contrast
High Contrast
Negative Contrast
Negative Contrast
Light Background
Light Background
Links Underline
Links Underline
Readable Font
Readable Font
Reset
Reset