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Lucks Lane Veterinary Clinic
Small Mammal History Form
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Small Mammal History Form
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First Name(required)
Last Name(required)
Email
Name of Animal(required)
Species / Breed(required)
Age(required)
*
— select —
Sex of Pet(required)
*
— select —
Length of time owned?(required)
*
— select —
Reason for today's visit?(required)
Any previous medical problems?(required)
Place of Purchase?
— select —
How often is your pet handled?(required)
*
— select —
Indoor
Outdoor
Yes
No
Where is the cage located?(required)
Cage type:(required)
Cage size:(required)
Cage bedding:(required)
Describe how often the cage is cleaned and what is used to clean the cage:(required)
Types of cage furniture:(required)
What toys are available?(required)
What are the toys made of?(required)
Yes
No
If yes, please specify:
Together
Singly
If not housed together, where are the other animals located?
What water source is offered?(required)
How often is water changed?(required)
How often is the water source cleaned?(required)
Yes
No
Brand:(required)
Quantity:(required)
Describe the remainder of the diet (hay, fruits, veggies, human food, etc):(required)
Yes
No
If yes, please list:
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