Emergency: (231) 922-0911
Join Our Team
Emergency: (231) 922-0911
Join Our Team
Book Appointment
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Home
About
Our Story
Our Team
FAQs
Reviews
Photo Gallery
Cat-Friendly Practice
Services
Resources
Our App
Payment Options
Emergency Contact
Online Forms
Photo Release Form
Dog & Cat Welcome Form
Chinchilla Welcome Form
Hedgehog Welcome Form
Rabbit Welcome Form
Rodent Welcome Form
Online Store
Online Pharmacy
Hill’s To Home
Contact
Companion Care Plans
Book Appointment
Hedgehog
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
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Maryland
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Northern Mariana Islands
Ohio
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South Carolina
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Texas
Utah
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Vermont
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Armed Forces Americas
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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
Hedgehog’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 hedgehog?
*
Yes
No
Hedgehog’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 Hedgehog 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 Hedgehog?
Yes
No
Daytime temperature in enclosure:
Nighttime temperature in enclosure:
Other household pets:
Diet/Feeding
Hedgehog’s Diet:
Basic, primary food(s)
How often are those offered?
How long does it take to eat each portion?
Other Foods offered
How Often?
Hedgehog 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
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CareCredit
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Email
This field is for validation purposes and should be left unchanged.
