Owner’s Name:_____________________________Date:_____________
Chicago Exotics, PC
An Avian and Exotic Animal Hospital
3757 W. Dempster St.
Skokie, IL 60076
847-329-8709
Owner’s Name:_____________________________Date:_____________
Your current address:__________________________________________
City:__________________________State:______________Zip:________
Your current phone number:
Home:_______________________Work:_________________________
Cell:_________________________Other:_________________________
Patient’s Name:______________Species:________________Sex:_______
Description (color, etc.)________________________________________
Spayed or neutered:_________Age:__________Date of Birth:_________
Place of patient’s origin and how long have you owned him/her?______
____________________________________________________________
Please list any current or ongoing medical problems:________________
____________________________________________________________
____________________________________________________________
Please list any prior medical problems, traumas, surgeries:____________
____________________________________________________________
____________________________________________________________
Please list any current medications:______________________________
Please list any known reactions/allergies to medications, vaccines, or anesthesia:___________________________________________________
____________________________________________________________
Current Diet:_________________________________________________
List Dates of most recent vaccines:_______________________________
Previous veterinarian or animal hospital:__________________________
How did you hear about us? Web_____phonebook________vet______
friend______________Other____________________________________
To the best of my knowledge, the above information is correct. If clarification of medical history is needed, I authorize you to contact my referring veterinarian. I understand that payment is due at the time services are rendered. I agree to pay all charges at the time my pet is discharged._______________________________________________
owner’s signature Date
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