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Home
Our Hospital
Our Doctors
Hospital Tour
Forms
Careers
Download Our PetDesk App
Services
Dental Care
Laser Therapy
Wellness Exams
Senior Wellness
Digital Radiology
Ultrasound
Pocket Pets
View All Services
New Clients
Payment Options
Shop Online
Contact Us
Make An Appointment
414-425-2339
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Rodent History Form
Rodent History Form
"
*
" indicates required fields
Owner's First Name
*
Owner's Last Name
*
Phone Number
*
Patient Name
*
Age
*
Sex
*
Male
Female
Species
*
Rat
Mouse
Breed
*
Color
*
Has your pet 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.
*
Coughing
Sneezing
Diarrhea/change in stool pattern
Nasal Discharge
Eye discharge or bulging eyes
Scratching or hair loss
Limping
Abnormal urination
Changes in appetite
Other
Please select all that apply
If other, please specify
*
Your Pet's History
Where did you get your pet?
*
Pet Store
Breeder
Private Party/Friend
Other
If other, please specify
*
How long have you had your pet?
*
Has your pet had any history of medical issues?
*
Yes
No
If yes, please specify
*
Is your pet 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 pet 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 pet have in their enclosure?
*
Are there any other pets in your home that have contact with your rodent?
*
Diet
What type of food(s) do you offer?
*
Amount fed
*
Have there been any recent changes in diet?
*
Yes
No
If yes, please describe
*
What type of water do you provide?
*
Sipper/Drip bottle
Bowl
How often is the water source cleaned?
*
A Day in the Life
What does a day in your rodent's life look like?
*
Are they allowed to roam the house? Supervised or unsupervised?
Is there anything else you'd like us to know about your rodent?
*
Signature
*
Comments
This field is for validation purposes and should be left unchanged.
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