Avian Intake Form

Welcome to Wynne Veterinary Clinic. As a new client we would like to get to know you and your bird. Please fill in the information, for our records, sign and return it to the receptionist.

Our goal is to make your pets visit as pleasant as possible. If you have any questions, problems or suggestions concerning your treatment or our policies please do not hesitate to ask our staff

Thank you for choosing Wynne Veterinary Clinic

Owner Information

Patient Information

Last Name________________Bird's Name________________
First Name________________Age/Hatch Date________________
Spouse________________Sex____ DNA Tested? ___Y___N
City_________State_____Zip_____Previous Veterinarian________________
Home phone________________May we obtain your pet's previous records? ___Y ___N
Second phone________________Micro-chip#________________
Drivers License #________________What do you feed your bird________________
Social Security #________________Do you use any dietary supplements?________________
Employer________________Cage Size________ Out of Cage Time________
Address________________Other birds/pets________________
Employer Phone________________Eating Normally?_____Y _____N
How Will you be paying today?
Cash______ Check______ Credit Card______
Droppings Normal? ___Y ___N

We only provide quality care to our patients. Quite often, a visit to the vet can be stressful to your pet. Dr. Wynne and her agents, servants and or representatives are released from any liability arising from the visit or treatment.

I acknowledge that I am financially responsible for all charges. To do this we require payment at the time of services. If it becomes necessary to initiate any action to collect any unpaid balances and late payment charges due on your account, you agree to pay the reasonable costs of collection including necessary attorney fees and court costs