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

Sex *

Unknown

Female

Male

Spayed/Neutered *

Unknown

Yes

No

Captive born or wild-caught? *

Captive born

Wild-caught

Unknown

Do you have temperature gauges in the tank? *

Yes

No

Sometimes

Are there any UVA/UVB light source(s)? *

Yes

No

Unsure

Aquatic habitat? *

Yes

No

If aquatic, do you have a water temperature gauge?

Yes

No

If aquatic, do you have a water filter?

Yes

No

Does your reptile have a hide box? *

Yes

No

Do you give any branches? *

Yes

No

Not applicable to species

Does your reptile ever go outside? *

Yes

No

Any cage or tank mates? *

Yes

No

Do you feed your reptile rodents? *

Yes, alive

Yes, fresh thawed

Yes, both alive and fresh thawed

No

Do you feed your reptile bugs? *

Please select all that apply.

None - I don't feed insects

Dubia Roaches

Mealworms

Superworms

Crickets

Waxworms

Other

Do you feed your reptile greens/vegetables? *

Yes

No

Sometimes

Do you feed your reptile fruit? *

Yes

No

Sometimes

Does your reptile leave any part of the diet uneaten? *

Yes

No

Sometimes

Do you ever soak or spray your reptile? *

Yes, soak

Yes, spray

Yes, soak & spray

No

Any previous illnesses? *

Yes

No

Are they eating? *

Yes

No

Unsure

Are they pooping? *

Yes

No

Unsure

If so, any problems shedding?

Yes

No

Unsure

Do you brumate your reptile? (Does your reptile hibernate/brumate?) *

Yes

No

Sometimes

Have you treated your reptile with any medications or supplements (including dewormers or vitamins)? *

Yes

No

Please check all that apply *

Other pets affected or ill

New cage mate introduced in the last 6 months

Change of type or source of food/water

Signs of weight loss

Vomiting

Decrease in activity level

Change in appetite

Change in water consumption

Appears itchy (rubbing on rocks, etc)

Diarrhea

New lumps or bumps

Difficulty breathing

Noisy breathing

Discharge from the eyes

Discharge from the nose

Access to potential toxins, for example grass treated with herbicide/pesticide, toxic plants

Access to foreign objects

None of the above