Page 1 of 2
Intake Form
Name
*
Sex
*
Sex
A
Female
B
Male
C
Unknown
Approx. Age
*
Species
*
Morph/Color
*
Examination
Examination Photo(s)
*
Click to choose a file or drag here
Accepts image files
Apparent Weight
*
Apparent Weight
A
Underweight
B
Healthy
C
Overweight
Aggressive
*
Aggressive
A
Yes
B
No
C
N/A
Eye Irritation or Discharge
*
Eye Irritation or Discharge
A
Yes
B
No
C
N/A
Nose Irritation or Discharge
*
Nose Irritation or Discharge
A
Yes
B
No
C
N/A
Wounds
*
Wounds
A
Yes
B
No
Stuck Shed
*
Stuck Shed
A
Yes
B
No
C
N/A
Missing Limbs/Digits
*
Missing Limbs/Digits
A
Yes
B
No
C
Unsure
D
N/A
Posture
*
Posture
A
Normal
B
Abnormal
C
Unsure
D
N/A
Femoral Pores
*
Femoral Pores
A
Normal
B
Abnormal
C
Unsure
D
N/A
Nails
*
Nails
A
Normal
B
Trim Needed
C
Unsure
D
N/A
Skin Abnormalities/Scars
*
Skin Abnormalities/Scars
A
Normal
B
Abnormal
C
Unsure
D
N/A
Impacted
*
Impacted
A
Yes
B
No
C
Unsure
D
N/A
Energy Level
*
Energy Level
A
Alert
B
Lethargic
C
Unsure
D
N/A
Parasites
*
Parasites
A
Yes
B
No
C
Unsure
D
N/A
Yellow Fungus
*
Yellow Fungus
A
Yes
B
No
C
Unsure
D
N/A
Hydration
*
Hydration
A
Good
B
Dehydrated
C
Unsure
D
N/A
Signs of MBD
*
Signs of MBD
A
Yes
B
No
C
Unsure
D
N/A
Signs of Necrosis
*
Signs of Necrosis
A
Yes
B
No
C
Unsure
D
N/A
Signs of Scale Rot
*
Signs of Scale Rot
A
Yes
B
No
C
Unsure
D
N/A
Signs of Mouth Rot
*
Signs of Mouth Rot
A
Yes
B
No
C
Unsure
D
N/A
Mouth Sores
*
Mouth Sores
A
Yes
B
No
C
Unsure
D
N/A
Tail Condition
*
Tail Condition
A
Original
B
Regrown
C
Missing
D
Unsure
E
N/A
Additional Examination Notes
Intake Performed By
Name
*
*
Signature
*
Signature
Intake Date/Time
*
*
Submit