Rabbit / Rodent Questionnaire

Which practice would you like to register with?

Location:

Surgery Contact:

CLIENT INFORMATION

Owner's Full Name*:

Co-Owner's Full Name:

Phone Number*:

Secondary Phone Number:

Contact Email Address:

Address*:

City:

Province*:

Postal Code*:

PATIENT INFORMATION

Your pet's name*:

Pet Species/ Breed*:

Your Pet's Age (and D.O.B if known)*:

Pet's Gender:

Date Acquired*:

Source*:

Where is the animal kept?*:

Describe the cage enclosure (Type, size, objects in cage, etc.):

What material is used to line the bottom of the cage/litter pan?:

Is the animal kept in a cage with other animals?*:

Yes
No

Is your pet kept near guiniea pigs?:

Yes
No

Please list all other pets in your household:

How much time does your pet spend outside of the cage?:

Is your pet supervised when it is out of the cage?:

How much time does your pet spend outdoors:

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

List any recent changes in your pet's environment:

DIET

This section is VERY important. Be as accurate as possible. Indicate which foods are eaten and in what amounts each day (by number, weight, or approximate volume).

Rabbit / Rodent Questionnaire

Which practice would you like to register with?

CLIENT INFORMATION

PATIENT INFORMATION

DIET

REPRODUCTIVE

REASON FOR VISIT

Rabbit / Rodent Questionnaire

Which practice would you like to register with?

CLIENT INFORMATION

PATIENT INFORMATION

DIET

REPRODUCTIVE

REASON FOR VISIT

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