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ONLINE PHARMACY

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- Blog
Team
Species
- Birds
- Mammals
- Reptiles
Wellness Plan
Resources and videos
RX Refill
Contact us

Client Registration

Home / Client Registration

Please fill out completely. It may be necessary at some time to contact you concerning needed treatment or the progress of your pet, and this information can save us valuable time. Some of the information is also necessary in order to accept checks for payments. Thank you.

You may also download and print the form.

Avian Form Avian Form

small4

AVIAN & MAMMALS

RM_Stats
Email^*
Date^*
Name^*
Last Name^*
Home phone & Cell phone^*
Address/State/Zip code^*
Email^*
Are you employed ?^*
Yes

No

Other
If Yes, where:^*
Telephone^*
Is your spouse employed?^*
Yes

No

Other
If Yes, where
Phone/Address/How long/City/State/Zip^*
How did you find out about the Exotic Bird Hospital?^*
Google

Facebook

Youtube

Friend

Another Vet

Other
PAYMENT FOR SERVICES DUE WHEN RENDERED
Method of payment:^*
Check

Cash

Mastercard

Visa

Discover

Driver\'s license # and State^*
Identification necessary in order to accept checks and credit cards. Nearest relative not living with you:
Name^*
Phone^*
Address/State/Zip code^*
Relationship^*
---------------PATIENT INFORMATION-----------------
Pet name^*
Owner Name^*
Species^*
Age^*
Sex^*
Male

Female

Unknown

Origin^*
Captive bred

Hand fed

Wild Caught

Companion

Breeder

Unknown

Acquired from^*
Handfeeding formula raised on
Diet^*
Pellets

Seed

Fruit & veggies

Table food

Handfeeding

Other

Please specify:
Location in the house or Aviary:^*
Additional animals in household (list species, names & ages)^*
Recent Changes in:
Diet/ Yes or No/ Details^*
Food/Yes or no/Details^*
Circumstances/Yes or No/Details^*
Does anyone smoke in the house?^*
Yes

No

Presenting Complaint^*
Pre-existing Problems^*
I grant Exotic bird hospital and any and all its subsidiaries full permission to use any and all images taken of me or my pets for the sole use of education, advertisement and promotion. This includes but is not limited to Facebook, Twitter, Youtube videos and other Social media sites, websites blogs and website display. I certify that I am 18 years of age or older.
Yes/No (If, yes please Initials)

Reptile Form Reptile Form

reptiles

REPTILES

RM_Stats
Email^*
Date^*
Name^*
Last Name^*
Home & Cell phone^*
Address/City/State/Zip code^*
Email^*
Are you employed ?^*
Yes

No

If Yes, Where:
Phone^*
Address/How long/City/State/Zip code
Is your spouse employed ?^*
Yes

No

If Yes, where:
Telephone
Address/How long/City/State/Zip code
How did you find out about the Exotic Bird Hospital?^*
Google

Facebook

Youtube

Friend

Another Vet

Other

PAYMENT FOR SERVICES DUE WHEN RENDERED
Method of Payment:^*
Check

Cash

Mastercard

Visa

Discover

Identification necessary in order to accept checks and credit cards:
Driver\'s license # and State^*
Nearest relative not living with you:
Name^*
Contact number^*
Address/City/State/Zip code
Relationship^*
---------------PATIENTE INFORMATION----------------
Pet name^*
Owner name^*
Species^*
Age^*
Sex^*
Male

Female

Unknown

Origin^*
Captive bred

Wild Caught

Where did you obtain your reptile?^*
Do you own other reptiles?^*
Yes

No

If Yes, what species and do they share the same enclosure?
Do you use vitamins and/or mineral supplements ? If so, what products do you use, how much, and how often:^*
What is this reptile usual diet:^*
If insectivorous, what type of insects are you feeding?
Do you gut load and with what?^*
how often do you feed?^*
What kind cage/enclosure is this reptile kept?^*
Enclosure % humidity?^*
What substrate is used on the bottom of the cage?^*
What kind of lighting is used (type of bulb):^*
What Cycle are the lights on (how many hours are they on-time off/on):^*
When was the bulb last changed?^*
What kind of heat source is used? Basking temp? Hot side? Cool side?^*
What is your water source?^*
Has this reptile been seen by a veterinarian before?^*
Yes

No

If so, where and why?
May we obtain a copy of the records?
Yes

No

Does anyone smoke in the house?^*
Yes

No

Presenting complaint:^*
I grant Exotic bird hospital and any and all its subsidiaries full permission to use any and all images taken of me or my pets for the sole use of education, advertisement and promotion. This includes but is not limited to Facebook, Twitter, Youtube videos and other Social media sites, websites blogs and website display. I certify that I am 18 years of age or older.
Yes/No (If, yes please Initials)

Location

11744 Beach BlvdSuite 107Jacksonville, FL, 32246

904.256.0043

frontdesk@exoticbirdhospital.com

HOSPITAL HOURS

We are open for appointments
8-00 am until 6pm Monday to Saturday
Emergencies during regular working hours do carry an additional fee.

Online Appointments

Request Appointment Here

Find us online

Request RX Refill Here

PREPAYMENT $83.00

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Accepted Payments

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11744 Beach Blvd, Jacksonville Fl 32246 PH: (904)256-0043