Call: 978-632-7110
Text: 978-632-7110
73 Eaton Street Gardner, MA 01440

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Avian History Form

Please complete the form below to submit the Avian History Form online. You can also click the button below to download and print the form.

Owner’s Name *

First

Last

Email *

Pet’s name *

Species *

Date of birth/Age *

Sex *

Male
Female

Sexed by *

DNA
Endoscopy
Surgery

Origin *

Captive Bred
Wild Caught Import
Unknown

How long have you had this bird? *

Where did you obtain this bird? *

Where did you obtain this bird? (copy) *

Does your bird lay eggs? *

Yes
No

If yes, please give details (how many/how often) *

When did your bird last molt? *

How often does your bird been molt? *

Is your bird vaccinated? *

Yes
No

If yes, which vaccines *

Does your bird get wing trims? *

Yes
No

If yes, how often *

Do you have other birds or pets? *

Yes
No

If yes, please give details *

Have you or your bird had any contact with other birds in the last 30 days? *

Yes
No

If yes, please give details *

When was the last bird added to your collection? *

REASON FOR PRESENTATION TODAY

What is the primary complaint or what signs have you noticed? How long have these problems been present? What health problems has your bird had previously? *

What health problems has your bird had previously? *

Has your bird received any treatment in the last 30 days?

Yes
No

If yes, please give details (what was used, dosage, how often, duration): *

Have you noticed any change in your bird’s behavior? *

Yes
No

If yes, please give details *

Any other birds at home with similar symptoms? *

Have any other animals or persons in the household had any illness in the last 30 days? *

Diet

How often do you feed your bird *

Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume): *

Indicate which foods are eaten and in what amounts (by number, weight, or approx. volume)

Seed mixtures brand *

Seed mixtures amount

Pellets Brand

Pellets amount

Fruits and/or vegetables type

Fruits and/or vegetables amount

Meat type

Meat amount

Other

Do you use any nutritional supplements? *

Yes
No

If yes what, how much, and how often? *

What water supply do you provide? *

Tap water
Bottled water

If tap, how old is your home? *

How is water provided? *

Bowl
Dripper system
Spray

How often is the water changed? *

Do you use any water supplements?

Yes
No

If yes, please give details *

Have you noticed any changes in feeding or drinking behavior? Please give details *

Have you noticed any changes in droppings (fecal material, urine and urates?) Please give details *

Cage/Environment

Where is the cage located? *

What is the cage made of? *

Cage size *

What furnishings are present? *

Nest box
Swingss
Mirrors
Perches
Toys
Other

What type of perches? *

What types of toys? *

Do you bathe your bird? *

Yes
No

If yes, how and how often? *

How often is the cage cleaned? *

What cleaning/disinfectant agents are used? *

What percentage of time does your bird spend inside and outside of its cage?

Inside *

Outside *

Is the animal supervised when out of the cage? *

Yes
No

Is your bird flighted? *

Yes
No

Do you allow your bird to fly around the home? *

Is your bird exposed to full spectrum (UVA and UVB) lighting? *

Yes
No

How many hours a day? *

How many hours of sleep does your bird get each night? *

Where does your bird sleep? *

Does anyone in the household smoke? *

Yes
No

Do you use any aerosolized products? *

Yes
No

Have you used any teflon coated or other non-stick pans recently? *

Yes
No

Have there been any changes in the bird’s environment in the last 3 months? *

Yes
No

If yes, please explain *

Ready for a visit?

We deliver veterinary care with respect and compassion to the pets of Gardner, Westminster, Ashburnham, Templeton, and beyond. Easily request an appointment for your pet using our online system on PetDesk and keep up with your pet’s health by downloading our app!

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Have a question?

Complete the form below and a member of our team will get back to you as quickly as possible.

Name *

First

Last

E-mail *

Phone

I consent to receive SMS text messages from Gardner Animal Care Center. Msg & data rates may apply. Reply STOP to opt-out. *

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How may we help you? *

Phone



Where to Find Us

73 Eaton Street
Gardner, MA 01440

Click here for directions.

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How to Reach Us

Call: 978-632-7110

Text: 978-632-7110

Fax: 978-632-7354
Email: [email protected]

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Our Hours

Mon – Fri: 8:00 am – 7:00 pm
Sat: 8:00 am – 2:00 pm
Sun: Closed

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