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Home
About
About Us
Patient Center
New Patients
Patient Gallery
Special Offers
Request An Appointment
Client Forms
Referral Centers
Resources
Pet Links
For New Puppy Owners
For New Kitten Owners
We Choose AAHA
Community Outreach
Awards
25 Year Anniversary
Joel’s Memorial Pet Garden
Our Team
Veterinarians
Our Care Team
Services
Dogs and Puppies
Cats and Kittens
Exotics
Emergency Services
Boarding
Doggie Daycare
Pet Grooming
Obedience Training
Laser Therapy
Wellness Plans
Our Blog
Our App
Join Our Team
Online Pharmacy
Refills at GACC
Contact
Appointment
Poultry History Form
Please complete the form below to submit the Poultry History Form online. You can also click the button below to download and print the form.
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Owner’s Name
*
First
Last
Email
*
Pet’s name
*
Species
*
Age
*
Sex
*
Female
Male
How long have you had this bird?
*
Does your bird lay eggs?
*
Yes
No
If yes, how frequent does she lay?
*
Does your bird lay year round?
*
Yes
No
Do you know when she last laid?
Is your bird vaccinated for Marek’s?
*
Yes
No
Unknown
Any other vaccines
*
How many birds are in this flock?
*
Where is this bird in the “pecking order?”
*
List any other pets you have beside this flock:
When was the last bird added to this flock?
*
Reason for presentation today
What is the primary complaint or what signs have you noticed? How long have these problems been present?
*
Describe any health problems previously found in this flock:
*
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):
*
Are any other birds in the flock showing similar symptoms?
*
Yes
No
Have any other animals or persons in the household had any illness in the last 30 days?
*
Diet
List everything fed to the flock (Include brand names of commercial foods, human foods/scraps, etc.)
Describe how the food is stored
Do you use any supplements or medications?
*
Yes
No
If yes describe type, frequency, dose and type of delivery (i.e. via water, food, etc)?
*
Coop/Environment
Describe your coop layout (size, materials, etc)
*
Describe outdoor space (caged vs free roam)
*
Describe cleaning procedures
*
Describe biosecurity protocols
*
Has your coop ever been tested for lead?
*
Yes
No
Has your soil ever been tested for lead?
*
Yes
No
Results if applicable
*
What water sources are available to your flock?
*
Bowls
Kiddie pool
Third Choice
Drip system
Lake/pond
Other
If other, please explain
*
How often do you clean water source?
*
Submit