Amphibian History Form – Kensington Bird & Animal Hospital

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Amphibian History Form

Pet's Name*
Owner's Name*
First Last
Species*
Age - Months/Years (if known)*
Gender*
- Male
- Female
- Unknown
If gender is known, how was it determined?
How did you acquire your pet?*
- Wild Caught
- Domestically Bred
- Imported
- Pet Store
- Other
If other, please explain:
What type of enclosure?*
- Aquarium
- Pond
- Indoor
- Outdoor
- Other
If other, please explain:
How big is the enclosure (gallons or dimensions)?*
How often do you clean the enclosure?*
Any other amphibian living in enclosure?*
What type of items are in the enclosure (select all that apply)?
- Select All
- Natural Branches
- Fake Branches
- Foliage
- Real Plants
- Stones
- Dig Box
- Hide Box
- Other
If other, please explain:
What is at the bottom of the enclosure?*
- Towel
- Tile
- Rubber Mat
- Playsand
- Bare
- Gravel
- Dirt
- Moss
- Other
If other, please explain:
What is the basking temperature?*
What is the daytime temperature?*
What is the nighttime temperature?*
Humidity?*
Do you use a thermostat?*
- Yes
- No
Do you use a thermometer?*
- Yes
- No
Do you use a hygrometer?*
- Yes
- No
How do you heat the enclosure?*
- Heat Cable
- Heat Tape
- Room Heater
- Under Tank Heater
- Light Bulb
- Ceramic Heat Emitters
- Mercury Bulbs
- Hot Rocks
How much is aquatic?*
- Full
- Half
- Isolated Dish
- None
How do you control the humidity?*
- Humidifier in Room
- Mister/Fogger
- Drip System
- Sprayer
How is water offered?*
- Dish
- Tray
- Dropper/Mister
- Portion of Cage
- Soaking
How is water filtered?*
- Intank Filter
- Biowheel
- Canister
- None
What is PH of water?*
What type of water?*
- Aged
- Distilled
- Bottled
- Taped
What strength of UV bulb?*
- 2.0
- 5.0
- 10.0
- Other
If other, please explain:
How often do you replace the bulb?*
What brand of bulb do you have?*
- Repti-Sun
- Sun Glow
- Other
What do you feed your pet (type and brand if known)?*
How often do you feed your pet?*
How often does your pet defecate?*
What supplements do you use?*
- Calcium
- Calcium with D3
- Multi-Vitamin
How often do you use supplements?*
Has the amphibian been seen by another veterinarian?*
- Yes
- No
If yes, please include name and phone number of veterinarian:
Additional comments/concerns:*
Upload photo of enclosure (optional)

Contact.

977 Farmington Ave
Kensington, CT 06037

Phone: (860) 828-7736

Fax: (860) 829-0594

Hours.

Monday – Friday
8:00am – 5:00pm

Saturday
8:00am – 12:00pm

Sunday
Closed

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About Us
Emergency Care
Clinic Forms
- Forms
- Forms
Services
Pet Health
Contact Us
- Make An Appointment
Wildlife & Disease Outbreaks

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