Phone *
Email *
Reptile's Name *
Please explain your pet’s illness: *
Species *
Age *
Size when acquired? *
How was the sex identified? *
Where has your pet been seen previously? *
If other, please specify *
Length of Quarantine *
What is your animal's cage made out of (glass, wood, PVC, etc)? *
Cage dimensions/size *
Please describe: *
Cage decor/set-up description *
If so, what kind (glass, plastic, mesh, etc.)? *
Type of Substrate/Bedding *
Substrate depth *
Frequency of Cleaning *
What kind of heat source(s): *
How often do you do routine water changes? *
How many gallons of water do you replace at each change? *
How often do you check your tanks water parameters (pH, GH, kH, Nitrate, Nitrite, Ammonia, etc)? *
What water source do you use for your water changes (ex. Tap water, well water, RO water, etc)? *
Do you treat your water with a product to remove chlorine/chloramine prior to adding it to your aquarium? *
If so, how much and how often? *
pH *
Nitrate *
Nitrite *
Ammonia *
KH *
GH *
Water temperature *
Land basking temperature *
Warm ambient/air temperature *
Cool ambient/air temperature *
Basking/surface temperature *
How is humidity maintained? *
How is water supplied? *
Humidity: *
If yes, how often? *
If yes, how long? *
Brand *
How often changed? *
When was it last changed? *
What is the output? *
How many hours of light per day? *
Any other types of light(s)?
Diet: *
Where do you purchase the food? *
Please describe *
How often do you feed your reptile? *
Last time your pet was fed? *
Last time your pet ate? *
If so, what kind and how often? *
Last Shed *
If snake, was shed complete?
If yes, give details *
Main concern/problem for this pet (include duration of symptoms and any attempted treatments at home). *
Additional Pet's Name
Pet Species
Additional Pet's Name
Pet Species
What provider? *
