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Emergency: (231) 922-0911
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Companion Care Plans
Request Appointment

Home
About
Services
Resources
Online Forms
Online Store
- Online Pharmacy
- Hill’s To Home
Contact
Companion Care Plans
Request Appointment

Chinchilla Welcome Form

Please complete this form as completely and accurately as possible so we can get to know you and your chinchilla(s) before your visit.

a gray chinchilla in a cage

Chinchilla Welcome Form

"*" indicates required fields

Owner's Name*

First Last

Owner's DOB*

MM slash DD slash YYYY

DL#*

Today's Date*

MM slash DD slash YYYY

Spouse Name

Street Address*

Address Line 1 Address Line 2 City State ZIP Code

Home Phone*

Cell Phone

Email Address*

Spouse Phone

Work Phone

Employer

Emergency Contact Name*

Emergency Phone

How did you learn of our hospital?*

Internet

Facebook

Website

Other Veterinarian

Client Referral

Sign/Drive By

Phone Book

Other

Who referred you?

Pet Details

Chinchilla’s Name*

Species/Breed/Variety*

Sex*

Male

Neutered Male

Female

Spayed Female

Weight*

Date of Birth*

MM slash DD slash YYYY

Color*

Length of time in household*

Do you have a second chinchilla?*

Yes

No

Chinchilla’s Name*

Species/Breed/Variety*

Sex*

Male

Neutered Male

Female

Spayed Female

Weight*

Date of Birth*

MM slash DD slash YYYY

Color*

Length of time in household*

Housing

Our Chinchilla has access to: (check all that apply)*

Entire House

Yard

Fenced Area

Exercise Pen

Other Special Quarters?*

Cage Size*

length X width X height

Share cage with other Chinchilla?

Yes

No

Daytime temperature in enclosure:

Nighttime temperature in enclosure:

Duration of light: (In Hours)

Duration of dark: (In Hours)

Hours in direct sunlight?

Lights turned on/off by family?

Yes

No

Other household pets:

Diet/Feeding

Chinchilla’s Diet:

Pelleted Diet (%)

What Percent of diet (%)

Brand?

Fresh Produce (%)

What Percent of diet (%)

Types/how often?

Timothy Hay (%)

What Percent of diet (%)

Alfalfa (%)

What Percent of diet (%)

Other Foods (%)

What Percent of diet (%

Types?

Chinchilla drinks from a...

Bottle

Bowl

History

Please list briefly any previous health problems, including when you noticed and when and how they were resolved:*

Adverse reactions to medications?

Date of last fecal parasite test

Results of Test

Reason for today’s visit

If for illness or injury, please include date first noticed, changes observed during the problem, methods of treatment used (if any), and any other important, pertinent details

Authorization*

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal(s). I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. I also authorize the hospital to use photos and/or other likeness of myself and/or my pet(s) for their medical record or other purposes. Must be 18 or older to authorize.

Signature of Owner*

Date*

MM slash DD slash YYYY

Method of Payment

Cash

Check

MasterCard

Visa

CareCredit

Discover

American Express

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

Book an Appointment!

Connect with us! Companion Animal Hospital proudly serves the communities of Williamsburg, Acme, Kingsley, Lake Ann, Interlochen, Elk Rapids, and surrounding areas. Click the button below to schedule an appointment now, or download our app to keep track of your pet’s health.

Request Appointment Download App

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Have Questions?

Get in touch. Complete our form, and a member of our team will be in touch with you shortly.

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Address

1885 Chartwell Drive
Traverse City, MI 49696

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Contact Information

Phone: (231) 935-1511
Email: reception@cahtc.com



Hour of Operation

Mon & Thurs: 7:30 am – 5:30 pm*
Fri: 7:30 am – 5:00 pm*
Sat & Sun: Closed
* Phones turn off a half-hour prior to close

Name *

First

Last

Email *

Phone

How can we help you? *

Name

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