Avian Exam Form
Avian Exam Form
General Information
Today’s Date
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Date of Appointment
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Client Name
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Client Name
First Name
First Name
Last Name
Last Name
Phone Number
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Email
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Patient Information & History
Bird’s Name
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How old is your bird?
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Is your bird a male or female?
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DNA confirmed male
DNA confirmed female
Believed to be male
Believed to be female
Unknown
How has your bird’s overall health been?
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Excellent – no concerns
Good – minor concerns
Fair – some concerns
Poor – significant concerns
Please elaborate on any concerns
What medications, supplements, or treatments does this bird receive?
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What brand & form of food are you feeding this bird? (ex: Zupreem, Mazuri, Nutriberries, etc)
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How much food are you feeding this bird and how often? (ex: 1/4 cup twice daily)
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Does your bird enjoy fruits and/or veggies?
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Any changes in eating, drinking, urination, defecation, or behavior since last visit?
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Yes
No
Please explain changes in eating, drinking, urination, defecation, behavior
Husbandry & Services
How big is your bird’s cage? What is it made of?
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What type of enrichment does your bird have?
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Does this bird need any additional services while with us today?
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Nail trim
Beak trim
Wing trim
None
Consent to Treatment
Does this bird have a history of requiring injectable sedation due to high fear, anxiety, stress, or aggression?
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Yes
No
*Patient charts will be reviewed by staff upon receipt. If your bird’s chart states injectable sedation is required and “no” is selected, we will have you sign documents at drop off*
Authorization for Injectable Sedation
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signature
keyboard
Clear
I authorize the following monetary amount for additional services outside of the cost of the annual wellness package
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$250
$400
None
I understand that NHPC may not contact me regarding the status of my pet prior to 4:00pm, unless there is an emergency.
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Yes
No
Drop-offs are triaged and worked on in between scheduled appointments
Signature
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signature
keyboard
Clear
Submit
If you are human, leave this field blank.
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