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
Rabbit
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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Armed Forces Americas
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State
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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
Pet Details
Rabbit’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
*
Females only: How many litters?
When was last litter?
Do you have a second rabbit?
*
Yes
No
Rabbit’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
*
Females only: How many litters?
When was last litter?
Housing
Our Rabbit has access to: (check all that apply)
*
Entire House
Yard
Fenced Area
Exercise Pen
If Rabbit lives primarily in a hutch, Hutch Size:
*
length X width X height
Indoor Cage Size
*
length X width X height
Other Special Quarters?
*
Daytime temperature in enclosure:
Nighttime temperature in enclosure:
Type of Bedding
Is rabbit litter box trained?
Leashed Trained?
Exposure to shows or other rabbits?
Share cage with other Rabbits?
Yes
No
Other household pets:
Diet/Feeding
Rabbit'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 (%)
Table Foods (%)
What Percent of diet (%)
Types?
Rabbit 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
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Check
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CareCredit
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American Express
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Name
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