Chicken and Duck New Patient Form

"*" indicates required fields

Client Information

Name*

First

Last

Phone*

History

Pet's Name*

Species*

Age*

Sex*

Male

Female

Unkown

Where did you get your bird?*

How long have you owned your bird?*

How many birds are in your flock?*

Do they get along?*

Do you have a mixed flock (ie multiple types of poultry)*

Yes

Does your mixed flock interact directly?

Has your bird been to a vet before?*

Yes

Where?

Any prior medical concerns?

Do you have any medical records?

Is your bird vaccinated for Merrick's disease?

Is your bird on any medications?

If Your Bird is Female

Does she regularly lay eggs?*

Yes

How often?

Last egg produced?

Are the eggs being consumed?

Have any malformed or abnormally shelled eggs been produced?*

Is your bird showing any broody behavior now (i.e. hiding in dark places, prolonged sitting in nest box without moving, feather loss on belly, etc)?*

Diet

Describe your bird's diet. What food items are actually consumed & in what proportions?*

Is your bird on a pelleted diet?*

Yes

Brand?

Amount and frequency?

Poultry seed/scratch?*

Yes

Brand?

Amount and frequency?

Veggies/fruits offered?*

Yes

Types?

Amount and frequency?

Other treats/foods?*

Yes

Types?

Amount and frequency?

What water source is offered?*

How often is it cleaned?*

Any supplements or grit (ie oyster shell or powdered) provided?*

Yes

Type, amount, and frequency?

How is it provided?

Lifestyle and Habitat

Has your bird been exposed to any "new" birds recently?*

Yes

This includes recently acquired birds AND bird taken out of the home for bird shows, grooming, boarding, etc

Do you quarantine newly acquired birds prior to introducing to the flock?*

Yes

How long?

Are they fully separated?

Is there any possible exposure to wild birds?*

Yes

Does your bird live in an outdoor coop?*

Yes

What size is the coop?

What is the coop made of?

Is there coop wire? If so, how far is it buried?

What substrate is in the coop?

How often is the coop cleaned and with what?

Is there a night time coop or nesting box available?

Are there heat lmaps available? If so, what is the typical coop temperature?

Are dust baths available? If so, what material?

Enrichment

Does your bird spend time outside of their coop?*

Yes

How often and for how long?

Do they get put up at night?

Does your bird interact with any other animals? What kind?*

Is your bird routinely handled/interacted with?*

Yes

Who handles them?

Signature*

Date*

MM slash DD slash YYYY

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.