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207-825-8989

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Prescription Refill

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Home
About Us
- Meet Our Staff
- Photo Gallery
Services
Exotics
- Exotic Veterinary Care
Resources
- Payment Options
Kindred Community
- Community Photos
- Pet Adoption Application
Pharmacy
- Prescription Refill Request Form
Join Our Team!
New Patient Forms
Contact
Book Appointment

We are currently accepting new clients!

Amphibian History Form

Please fill out the following questions as accurately as possible.

Amphibian History Form

Owner Name *

First

Last

Email *

Phone Number

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Information

Name *

First

Last

Species

Age

Length of time owned

Sex *

If female, spayed? *

Yes
No

Acquired from

Any other reptiles in the house? *

Yes
No

Please list: *

Any interaction between reptiles? *

Yes
No

When was the last reptile brought into the house?

Were they quarantined? *

Yes
No

Any other reptiles showing signs of illness? *

Yes
No

Environment (fill out what applies to your species):

Please include a picture of the cage

Drag & Drop Files, Choose Files to Upload

Please describe cage setup

Cage size

Ventilation

Cage furniture present

Substrate (material lining the bottom of the cage) type

Frequency of cleaning

Disinfectant used

Light cycle

Heat source (select all) *

Halogen Bulb
Ceramic Heat Emitter
Under tank heater
Heat rock
Other

Please specify *

UVB light present? *

Linear fluorescent bulb
Coil fluorescent bulb
Mercury vapor
Metal halide
None

Brand/type of UVB light

Age of UVB light

Temperature

Cool end

Warm end

Basking site

Unknown

Humidity

Water source (dish, mist, fogger, drip system):

Do you soak them?

Yes
No

Frequency

Nutrition (fill out what applies to your species)

Insects fed (type) *

Amount

Frequency

Whole food items (example: mice)

Frozen/thawed

Live

Amount

Frequency

Calcium supplement (brand)

Frequency

Multivitamin (brand)

Frequency

What is the water source

How frequently is it changed

Medical History

Any previous illnesses or injuries

Any current medications or supplements

Date of last examination *

Name and location of last veterinary hospital

Please send records from previous vet *

Drag & Drop Files, Choose Files to Upload

Today’s Visit

Layout Unknown house?

Reason for the visit *

Wellness exam
Sick exam

If sick, what are the symptoms: *

How long have they been showing symptoms

Have you tried any treatments?

I understand that a non-refundable deposit of $113.00 is required for all initial new client visits. *

I have read and understand.

Any other concerns?

Questions?

Get in touch! We look forward to hearing from you.

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Location

857 River Road
Orrington, ME 04474

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Contact Information

Phone: 207-825-8989
Fax: 207-825-8901
Email: reception@kindredvet.com

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Hours

Monday-Friday: 8:00  am–5:30 pm
Saturday: Closed
Sunday: Closed

Name *

First

Last

Email help Field

Email *

Phone

How can we help you? *

Website

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