Reptile 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 *

Species *

Lizard
Snake
Turtle/Tortoise
Other

Breed *

Sex *

Male
Female
Unknown

Neutered/Spayed *

How was sex determined?

Visually
Blood test
Surgically
Probes

If female, has she produced eggs or given birth to young in the past?

Yes
No
Unsure

Any identification (e.g., tattoo, microchip)?

Reptile's color(s) *

Where was your reptile acquired? *

Breeder
Pet store
Other

If other, please specify

How long have you had your reptile?

Your reptile is a... *

Pet
Breeder

Do you have any other pets? *

If yes, please specify ages and when acquired

When did your reptile last shed its skin?

Did the shed appear normal? (explain)

To your knowledge, has the reptile bitten anyone in the last 15 days? *

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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 reptile been sick previously? *

If yes, what was the issue/treatment?

Has any other veterinarian ever seen your reptile? If yes, please list the name of the veterinarian, hospital, date, and reasoning for the visit.

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

Blood work
Fecal
Parasite test
Skin parasite test
Radiographs (X-rays)
Other

If other, please specify

Has your pet ever traveled outside of Colorado?

If so, where and when?

Are you aware that reptiles carry the salmonella bacteria? If not, please ask us to explain.

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HOUSING

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

Indoors
Outdoors
Roams Free in House

Please indicate the percentage of time your reptile spends in each location

Please describe your reptile's enclosure (size, material)

Is your reptile housed alone?

If no, please describe

What is/are the heat source(s) in the enclosure?

Highest daytime temperature

Lowest daytime temperature

Highest nighttime temperature

Lowest nighttime temperature

Basking site temperature

What is the humidity inside the cage?

How are the heat and humidity measured?

Digital hygrometer/thermometer
Other

What is/are the light source(s)?

Is there a UVB and/or full spectrum light source?

Please describe hours of use

If yes, please describe (including brand and hours of use)

What substrate and other objects are in the cage (sand, gravel, newspaper, PVC, wood, hiding spots)?

How often is the cage cleaned?

Using which products?

Does your reptile hibernate or brumate (if applicable)?

Has your reptile's environment changed recently?

Do you soak your reptile?

If yes, where and for what time period?

If yes, please describe

If yes, how often and where?

Diet

DIET

What foods are offered to your reptile, and in what total percentages?

If live insects are fed, are they offered foot at home ("gut loaded") before being fed to your reptile?

Are any vitamin or mineral supplements offered?

Are any treats offered?

Any recent diet changes or new foods?

How is water offered?

What foods are eaten by your reptile, and in what total percentages?

If yes, with what product?

If yes, which ones and brand name?

If yes, please describe (type, how often, etc.)

If yes, please describe

How often is the water usually changed?

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 Copy

I hereby VALIDATE THAT I UNDERSTAND THAT IF I SELECT ABOVE TO HAVE CPR PERFORMED ON MY REPTILE, 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 Copy

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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