Date:
Your Name:
What is your bird’s name?
How old is your bird?
How long have you had your bird?
My bird is: MaleFemaleUnknown
Has your bird ever laid an egg? YesNo
I feed my bird: (Please check all that apply) Pelleted DietTable FoodPeanutsSeed Mix
What is the main reason for your bird’s visit today:
My bird has these symptoms: (Please check all that apply) ListlessDrinking a lotDrinking nothing Eating more than normalEating less than normalNot eating anythingLoose droppings / diarrheaVomitingSleeping more than normalVoice has changed or stopped talkingHaving trouble breathingTrouble perchingPicking feathersChewing skin and making it bleedFainting or seizure
Other:
Do you have other birds? YesNo
If so, how many?
What kind?
Check all the statements below that apply: My bird is: Always in his cageOut of the cage but in a confined area or on a perchLoose to run around the houseSometimes outside
At night, my bird is: In his cage, but, CoveredUncovered
In a different cage from his day cage CoveredUncovered
Has your bird been boarded recently, been to a pet store, or place where there are other birds. YesNo
Has your bird ever been sick in the past: (Check all that apply) Never sickSick and treated by a VeterinarianSick but got well with medication from pet store or without treatment.
Various tests may be needed to diagnose your bird’s problems. We often need to start with X-rays and/or an ultrasound exam. In some cases, bloodwork is necessary to help determine the health of your bird. Do we have your permission to do these tests if needed?
X-rays $125.00 (sedation required) YesNo
Ultrasound $45 YesNo
Bloodwork (typically $125) (We will call if cost exceeds) YesNo
*Signature:
Best Contact Phone Number:
