Avian Intake Form

Fields marked with an * are required

Client Information

Owner First Name *

Owner Last Name *

Your Birthday *

I am the legal guardian of this pet. *

Street Address *

City *

State *

Zip *

Email *

Phone *

Preferred Contact Method

Phone
Email

Secondary Contact

Secondary Contact Phone

How did you hear about us?

Patient Information

Pet's Name *

Age / Date of Birth *

Sex *

Male
Female
Unknown

How was sex determined?

Visually (sexual dimorphism)
Egg laying
Endoscopy
DNA

Bird's colors: *

Where was your bird acquired? *

Breeder
Pet store
Other

If other, please specify

How long have you had your bird?

Are there other birds in the household? *

If yes, please provide details about their housing conditions

Does this bird have current or recent exposure to other birds? (e.g. pet stores, boarding, outdoors/wild birds near cage?)

Do you have any other pets?

If yes, provide details and dates

If yes, what types?

To the best of your knowledge and belief, this animal has not bitten any person in the last 15 days (initial to certify) *

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Medical History

PATIENT Medical History

What are your pet's clinical symptoms?

When did you first notice those symptoms?

Are the symptoms...

Getting worse
Getting better
Staying the same

Please list all current medications and dosages

Has your bird been treated previously for this problem?

If yes, what was the treatment? How did your bird respond to the treatment?

Please provide the name and information for your bird's PRIMARY veterinarian/hospital

Have any tests been performed previously on your bird? (Select all that apply)

Chlamydophila test
Circovirus (beak & feather disease)
Polyoma Virus Test
Bornavirus Test
Other

Please specify test types, dates, and other information as necessary

Has your bird had previous treatment for any of the following conditions? (check all that apply) *

Bacterial Infection
Yeast Infection
Fungal Infection
Chlamydophila
Toxin Exposure
Parasites
Respiratory Disease
Heart Disease
Fractures
Gout
Kidney Disease
Liver Disease
Egg-related Problems
Malnutrition/Vitamin Deficiency
Feather Disorders
Intestinal Disease/Diarrhea
Lacerations/Skin Abrasions
Eye Problems
Nervous System Disease/Seizures
Beak Overgrowth
N/A

If you selected any of the above, please give as much detail as possible (e.g. date of illness, treatment received, and response to treatment)

Please list all previous vaccinations given, if known (type and date[s])

Has your pet ever traveled outside of Colorado?

If so, where and when?

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HUSBANDRY

Is your bird housed... (check all that apply)

Indoors
Outdoors

Is your bird taken outside?

If yes, when outside is your bird... (check all that apply)

In a cage
On your shoulder
Placed in a tree or freestanding perch
Other

If other, please describe

Do you maintain your bird fully flighted?

Does your bird shower or bathe?

Are their wings clipped?

If yes, how often do they shower or bathe?

CAGE

Your bird's cage location

Cage material

Cage size

Cage substrate (what is on the floor of the cage)?

Does your bird have access to toys in their cage? Copy

Can your bird access the floor material to play with or ingest?

Approximately how many hours of sunlight does your bird get per week?

PERCHES

Approximate number of perches on which your bird sits in a day?

Does your bird use perches made of or covered by: (check all that apply)

Sandpaper
Cement
Plastic
Rope
Wood
Other

If other, please describe

Does your bird have access to toys in their cage?

If yes, please describe these toys

Are any of the toys recent acquisitions?

HOUSEHOLD EXPOSURE TO POTENTIAL DANGERS OR TOXINS

Has your bird had contact with any of the following? (check all that apply) *

Cigarette Smoke
Perfumes
Scented lotions/creams
Fungicides, herbicides
Disinfectants
Heavy metals (lead/zinc)
Stained glass
Lead solder
Galvanized wire/screws/metal
Hair spray
Acetaminophen (Tylenol)
Peanuts, Brazil Nuts, seeds with bugs
Mite protector
Carpet Cleaners
Solid of plug-in air freshener
Mosquitoes
Chocolate
Avocado/guacamole
Plants
Ceiling Fans
Insecticides (ant/flea/roach/etc.)
Plastic coated heater, pans, fabric, nonstick cookware
N/A

Diet

DIET

Diet info

Many disease conditions in pet birds result from nutritional deficiencies. Despite the statements on seed and pellet products that these are complete diets, there is no standard to which these foods are held, and many of them are markedly deficient in various essential nutrients. The addition of fresh fruits, vegetables and table foods to the diet may add positive psychological components and some needed trace elements, but does not significantly alter the basic deficiencies seen in most commercial diets.

In order to determine to what extent nutritional deficiencies may be playing a part in your bird’s current or potential health problems, we must first determine the content of its diet. Please answer the following questions as accurately as you can. If needed, we can then assist you in reconstructing your bird’s diet to improve its health.

What are the main foods offered & consumed daily? *

Brand(s) of commercial diet if known

Other foods offered and consumed on a regular basis (fruits, vegetables, snacks, nuts, cereals, table foods)

Supplements given (vitamins, minerals, cuttlebone, grit, etc.)

How is water offered?

Does your bird dunk its food in water?

How often is the water usually changed?

BEHAVIOR

If you obtained your bird as a baby or know its early history, please answer the following questions.

Was your bird...

Parent reared
Hand reared
Reared with sibling
Reared with other young birds

How often do you handle your bird?

Does your bird exhibit any of the following behaviors? (check all that apply)

Screaming excessively or inappropriately
Refusing to come out of cage
Biting or attacking people
Biting or attacking certain individuals
Falling off perch at night
Overly reactive/frightened of sudden noises
Over bonding with certain individuals
Excessive sexual or masturbatory behavior
Feather destructive behavior
Other

If other, please specify

Treatment Authorization

TREATMENT AUTHORIZATION and information

I hereby authorize Evolution Veterinary Specialists, Inc., to perform medical and initial diagnostic/surgical procedures as required for diagnosis and treatment. I understand that I can terminate treatment at any time by contacting the doctor on staff.

If I have been referred to this hospital by another veterinarian, I understand that they will require a summary of the care and treatment provided by EVS in order to ensure that my pet’s care can be continued without interruption. I also understand that EVS considered the identification of a primary/referring veterinarian by me to be my authorization to release records and information to the veterinarian.

As leaders and teachers in the Veterinary Medical field, the doctors and staff of EVS may use medical case information for teaching, developing forms, providing continuing education, website, veterinary literature development, social media updates etc. I authorize the release of case/patient information for such purposes. Patient confidentiality will be maintained.

In the event of cardiac or respiratory arrest: *

I DO wish CPR to be performed
I DO NOT wish CPR to be performed (DNR)

Treatment Authorization

I hereby VALIDATE THAT I UNDERSTAND THAT IF I SELECT ABOVE TO HAVE CPR PERFORMED ON MY BIRD, I AM AUTHORIZING AND AGREE TO PAY THE ADDITIONAL MINIMUM FEE OF $640 FOR THE FIRST 6 MINUTES OF RESUSCITATIVE EFFORTS PERFORMED, AND AN ADDITIONAL $260 PER EVERY 4 MINUTES OF RESUSCITATIVE EFFORTS PERFORMED THEREAFTER.

I certify that I understand the treatment policy (initial) *

Financial Policy

Payment in full is due at the time of services. For hospitalized cases, a deposit of the low end of the treatment plan is required in advance and payment in full is due upon discharge from the hospital. We offer the following payment and credit options: Cash; ACH; Credit Cards (Visa, MasterCard, and Discover); Veterinary Payment Plans (Care Credit and Scratch Pay); Veterinary Pet Insurance: We work with all veterinary insurance providers and can supply you with any records you require in order to obtain reimbursement of funds spent on your pet during his/her EVS visit.

I have read and understand the treatment and financial policy and agree I am over 18 years of age.

Owner's (authorized party) typed name (indicates acknowledgement of financial policy): *

Media Release

Optional Media Release

I hereby grant Evolution Veterinary Specialists, Inc. permission to use my and/or my pet’s likeness in photograph(s)/video(s)/story in any and all of its publications and in any and all other media, whether now known or hereafter existing.

This release related to photographs/videos intended for use in any hospital publication or marketing or public relations nature, such as newsletters, brochures, websites/blogs/social networking sites, promotional items or other such material.

I will make no monetary or other claim against EVS Inc., for the use of this material

Owner's (authorized party) typed name (indicates acknowledgement of media release): *

Emergencies Only

Exam Fees

Emergency Exam Fee is due upfront before the pet is seen. Exam Fees are $175. The exam fee includes the cost of everything and everyone involved with getting your pet here and set up in our system, removing the opportunity to admit other cases, having your pet triaged/examined by any personnel (not only the DVM), and the convenience of being available 24/7.

Urgent Care Exam Fee is due upon making the appointment. Urgent care appointments can last longer than 1 hour if your pet requires in-depth medical attention such as sedation with a procedure. If our team determines that your pet requires emergent medical intervention, your pet will be immediately transferred to the emergency service, which is more appropriately equipped to provide emergency medical intervention. Our overall goal is to provide and offer the best possible and most appropriate care for your pet. The exam fee is $110 and the cancellation fee is $50 if you cancel less than 48 hours of the appointment.

Specialty Exam Fees may vary, but cancellation fees are $100 if you cancel less than 48 hours of the appointment.

Critical Emergency: Sign for Authorization of $800-1000 for Initial Diagnostics

**You will be provided with an estimate for further diagnostics and treatment as soon as we are able.

Owner's (authorized party) typed name (indicates acknowledgement of emergency exam or stabilization costs): *

By signing this intake form, you hereby consent to receiving emails from us containing promotional and relevant information. These emails may include hospital updates, exclusive offers, and other educational communications. You retain the right to unsubscribe from these emails at any time. Thank you for trusting Evolution Veterinary Specialists with the health of your pets.

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