Phone Number
Email *
Pet's Name (if applicable)
Please explain your pet’s illness: *
What Species Are You Bringing For An Exam? *
Where has your pet been seen previously? *
Main Concern/Problem for this pet *
Have you tried any at home treatments/remedies or medications on your pet already to address the problem they have? If so what and for how long? *
Any difference noted with what you did? *
Are there other affected individuals in your collection showing the same signs/symptoms or have different abnormal symptoms as the pet you're bringing today (please describe and include species affected if different then your pet coming for an exam)? *
How long have you owned this aquatic pet? *
Size when purchased (approximate)? *
Current length (approximate)? *
What other fish, invertebrates, coral, etc are housed in the same display tank with the aquatic pet you brought today?
What do you feed your pet? *
How often do you feed your pet? *
Is your pet currently eating? *
When is the last time they ate and what did they eat or show interest in? *
Aquarium Size (gallons) *
How often do you do routine water changes? *
How many gallons of water do you replace at each water change? *
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? *
After treating your water how long do you wait to use it in your tank? *
How often do you check your tanks water parameters (pH, salinity, kH, Nitrate, Nitrite, Ammonia)? *
What test product(s) do you use to check your water parameters (brands/kits)? *
Salinity *
pH *
kH *
Nitrite *
Nitrate *
Ammonia *
Tank Temperature *
If so, how much and how often? *
How often (if applicable) are these additives monitored with a test kit to determine levels before/after adding? *
Tank substrate?
Live Rock?
Coral?
How long do you quarantine stock (fish, coral, invertebrates, etc) before adding them to your tank? *
What was the last new addition to your display tank? *
If other, please specify *
Type of Filtration System *
What type of lighting do you have and what is the length of time it is on? *
What is your tank water turnover rate through your filtration system/sump? *
Or describe the setup (ex. Mounds of live rock, bare bottom with no rocks, PVC pipe for fish to hide in, etc)
Additional Pet's Name
Pet Species
Additional Pet's Name
Pet Species
What provider? *
