Avian History Form

Please tell us about you and your bird.

First Name*

Last Name*

Phone Number*

Email Address*

Pet's Name*

Species*

Gender*

If known, how has the gender been determined?

Age (best guess) or Date of Birth*

How long have you owned your bird?*

Where was your bird acquired?*

How often is your bird handled?*

Does your bird go outside?*

Environment

What type of cage does your bird have? *

Where in the house is the cage located? *

What are the dimensions of the cage?

How often is the cage cleaned?

Are there any other birds in the household? *
NoYes

If so, what breeds of bird and how many?

Do other birds share the cage? *
NoYes

If so, how many other birds?

Briefly describe the cage (perches, water bowls, bedding etc.) *

What kind of food do you feed your bird? *
PelletsSeedFruitsVegetablesTable FoodNutsOther:

Please specify brands and types of foods along with percentage of diet. *

Medical History

Do you have previous medical records? *
YesNo

Please list any previous medical problems.

Has your bird been tested for the following conditions? *
Chlamydia (Psittacosis)Psittacine Beak and Feather (PBFD)Neither of theseNot sure

If so, where?

Has your bird recently been exposed to other birds? *
(e.g. New bird, boarding)
YesNo

If so, please provide details.

Has your bird been wormed? *
YesNoNot sure

If so, what product was used?

Has your bird had a wing trim? *
YesNoNot sure

If so, who performed the wing trim?

Does your bird have access to heavy metals? *
YesNoNot sure

If so, please provide details.

Have there been any changes in your bird's environment? *

Are you concerned with any behaviour problems? *

Have there been any changes in your bird's droppings? If so, please describe. *

Are there any smokers in the house? *
YesNo

Have you noticed any of the following?
Decreased AppetiteIncreased AppetiteAnorexiaWeight LossVomiting/RegurgitationDifficulty BreathingTail BobbingLethargyFluffed FeathersDiarrheaStool Caked to VentFeather PickingNasal or Eye DischargeEgg LayingNesting/BroodyMasturbationOther:

What concerns do you have with your bird? Please describe *

Uploads

If you have photos of your bird's cage or medical records, please upload them below or email them to us.

Cage Photo 1:

Acceptable file types are JPG or PNG, up to 5mb in size.

Cage Photo 2:

Acceptable file types are JPG or PNG, up to 5mb in size.

Medical Records:

Acceptable file types are PDF, DOC, DOCX, JPG or PNG, up to 8mb in size.

Client Declaration

All payments are due at the time of service. If your bird is to be hospitalised, a deposit will be required at the time of admission with the remainder due at discharge. We accept EFTPOS, Visa and MasterCard.

I understand and agree with the above statement.

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