Rabbit, Guinea Pig Or Chinchilla Information Form
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1Rabbit, Guinea Pig or Chinchilla Information
Owner’s Last Name__________________________ First________________________
Patient’s Name _____________________________ Age/Birthday ________________
Species ___________________________ Breed _____________________________
Sex: Male
Female
Spayed/Neutered? Yes
No
Microchipped? Yes
No
How long have you owned your pet? _______________________
Is your pet primarily indoors or outdoors? ____________________
What type of cage and bedding?___________________________________________
Is this pet caged with other pets? (please list) _________________________________
Please list all food and treats given:
Pelleted Diet ____% Brands: ______________________________________________
Produce
____% Types/How often: ______________________________________
Hay
____% Type? _______________________________________________
Other foods
____% Types? ______________________________________________
Is their water source from a bottle
or bowl
How often changed? ________________
List any medications or supplements given:
_____________________________________________________________________
List any major surgeries or illnesses your pet has had:
_____________________________________________________________________
Previous Medical Records? Yes No
If yes, which clinic? _______________________ May we contact them? Yes No
Please circle any of the following medical issues you have concerns with for your pet:
Abnormal Behavior
Difficulty moving
Constipation
Diarrhea
Lethargy/Listlessness
Loss of Appetite
Coughing/Sneezing
Eye/Nasal Discharge
Itching/Hair Loss
Other:________________________________________________________________
This form can be faxed to us at (425) 947-9832
or scanned and emailed to
or brought in with you for your first appointment
Professional Fees are to be paid at time of services. For you convenience we accept
cash, check (with a valid driver’s license), visa, mastercard, american express, discover
and care credit. Returned checks are subject to a $35.00 fee.
Signature _____________________________________________ Date ___________
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