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

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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.

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? *

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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E-mail *

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How may we help you? *

Message

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Where to Find Us

73 Eaton Street
Gardner, MA 01440

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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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