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Rabbit History Form

"*" indicates required fields

Owner's First Name*

Owner's Last Name*

Phone Number*

Patient Name*

Age*

Sex*

Male

Female

Has your rabbit been spayed/neutered?*

Yes

No

Breed*

Color*

Does your pet have a microchip?*

Yes

No

If yes, please provide Microchip ID*

Has your rabbit been to a veterinarian before?*

Yes

No

If so, where?*

Reason for your visit*

Wellness

Sick

Tell us more*

Tell us a little bit about what is going on with your pet.*

Please select all that apply

If other, please specify*

Your Pet's History

Where did you get your rabbit?*

Pet Store

Breeder

Private Party/Friend

Other

If other, please specify*

How long have you had your rabbit?*

Has your rabbit had any history of medical issues?*

Yes

No

If yes, please specify*

Is your rabbit currently on any medications, supplements, or preventatives?*

Yes

No

If yes, please list all medications, supplements, and preventatives*

Please list dosage and amount

Housing

What type of enclosure do you keep your rabbit in?*

What type of bedding do you use & how often is it changed?*

Where is the enclosure located?*

What types of toys/enrichment does your rabbit have in their enclosure?*

Are there any other pets in your home that have contact with your rabbit?*

Diet

What type of food(s) do you offer your rabbit?*

Amount fed*

Have there been any recent changes in diet?*

Yes

No

If yes, please describe*

What type of water do you provide your rabbit?*

Sipper/Drip bottle

Bowl

How often is the water source cleaned?*

A Day in the Life

What does a day in your rabbit's life look like?*

Are they allowed to roam the house? Supervised or unsupervised?

Are they allowed outside? Leashed or out door enclosure, supervised or unsupervised?

Is there anything else you'd like us to know about your rabbit?*

Signature*

Comments

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