Owner's Name
(Required)
First
Last
Pet's Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
What species is your pet?
(Required)
What is the age of your pet?
(Required)
Do you know the gender (male or female)?
(Required)
Male
Female
I don't know
Where did you get them? (petstore, breeder, etc.)
(Required)
How long have you owned your pet?
(Required)
When was the last time they shed?
(Required)
Do they ever have trouble shedding?
(Required)
Does your pet mainly spend time inside or outside?
(Required)
What type and size tank do they have?
(Required)
Where is the tank located in your home?
(Required)
What type of substrate/bedding is in the cage?
(Required)
Are there any rocks, logs, plants, etc. within the tank?
(Required)
How often do you clean the tank and what do you clean with?
(Required)
What is the minimum and maximum temperatures within your tank?
(Required)
How do you measure the temperature and how often?
(Required)
Do you provide UVB light and for how long each day?
(Required)
When was the last time you replaced your UVB bulb?
(Required)
What is the humidity level within the tank?
(Required)
How do you provide water and how often is it changed?
(Required)
What types of food do you offer and roughly how much of each type?
(Required)
How often do you feed your pet?
(Required)
Do you provide calcium powder or any supplements?
(Required)
Do you have any other pets?
(Required)
Yes
No
What kind of other pets do you have?
(Required)
Does your pet live with any other pets in the same tank?
(Required)
Yes
No
Does your pet have any past medical history we should know about?
(Required)
Yes
No
Please explain any past medical history
(Required)
Are there any current medical issues or concerns occurring?
(Required)
Yes
No
Please describe the complaint as well as how long it's been going on
(Required)