Guardian name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary phone number *

(###)

###

####

Primary phone - able to text message?

Yes

No

Other phone number

(###)

###

####

Secondary contact name

First Name

Last Name

Secondary contact phone number

(###)

###

####

Secondary contact phone number - able to text message?

Yes

No

Is your pet microchipped? *

Unknown

Yes

No

Sex *

Unknown

Female

Male

Spayed/Neutered *

Unknown

Yes

No

Is the enclosure floor solid or wire? *

Solid Floor

Wire Floor

Wire Floor, with Resting Mat

Does your guinea pig have access to an outdoor run? *

Indoors only

Indoors, with supervised outdoor playtime only

Lives indoors and outdoors

Lives outdoors only

Does your guinea pig have free access around the home? *

Yes, always

Yes, sometimes

No, never

Does your guinea pig have any cage mates? *

Yes

No

Does your guinea pig have access to any electrical wires or houseplants/garden plants? *

Yes

Sometimes

No

Do you feed your guinea pig hay? *

Yes

No

Sometimes

Do you feed your guinea pig pellets? *

Yes

No

Sometimes

Do you feed your guinea pig greens/vegetables? *

Yes

No

Sometimes

Does your guinea pig leave any part of the diet uneaten? *

Yes

No

Sometimes

How do you give water? *

Bowl

Bottle

Both

Other

Any previous illnesses? *

Yes

No

Have you treated your guinea pig with any medications? *

Yes

No

Please check all that apply *

If female, could she be pregnant?

Other guinea pigs/pets affected or ill

New guinea pigs introduced in the last 6 months

Change of type or source of food/water

Signs of weight loss

Decrease in activity level

Change in appetite

Change in water consumption

Increase in amount of urine

Straining to urinate

Increased salivation

Sneezing

Diarrhea

New lumps or bumps

Hair loss

Itchiness/skin irritation/dandruff

Head shaking

Crusty material in the ears

Difficulty breathing

Noisy breathing

Discharge from the eyes

Discharge from the nose

None of the above