Bird New Patient Information Packet and Questionnaire

Florida Veterinary Behavior Service
Lisa Radosta DVM, DACVB

Krista Sirois DVM

Amy Learn VMD

Alison Gerken DVM

3421 Forest Hill Blvd, West Palm Beach, FL 33406

Phone:561-795-9398 Fax:561-795-8537

Email: info@flvetbehavior.com Web: www.flvetbehavior.com
Hello!

Thank you for making a behavioral medicine appointment for your pet. We have been providing specialty behaviorial medicine treatment to our patients in south Florida since 2007. My team and I are committed to helping your pet overcome his or her behavior disorders.

In this packet, you will find a registration form, tips for your pet's appointment and a patient questionnaire. Please fill out these forms and fax (561-795-8537) or email (info@flvetbehavior.com) them back to our office at least 3 days prior to your appointment. We will get in touch with your primary care veterinarian(s) directly to request your pet's medical records.

Please let us know what we can do to help you in the time leading up to your pet's appointment. You can find maps with our location information and direct numbers to those hospitals at our website:www.flvetbehavior.com.

We are looking forward to meeting you and your pet!

Sincerely,

The Florida Veterinary Behavior Service team

Florida Veterinary Behavior Service Registration Form and Waiver
Primary Pet Parent (your pet's medical record will be under this person)
Full Name

First Name Last Name
Primary Phone Number

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
E-mail

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Secondary Pet Parent
Full Name

First Name Last Name
Primary Phone Number

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
E-mail

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Would you like us to email you when new articles are uploaded onto our website? Emails are never shared with anyone!

Yes No
We may take pictures and videos as a part of your pet's appointment. Below is a consent form for use for images of your pet. When used, there will not no identifying information of the pet or yourself such as your name. Please consent below to whichever option works best for you.

My pet's pictures and videos are to be used only for my pet's medical record. My pet's pictures and videos can be used for my pet's medical record, textbooks, veterinary publications including journals, textbooks and electronic publications, veterinary presentations. Do not use my pet's picture for any purpose including in his or her medical records.
Who is your pet's primary care veterinarian? Please list the veterinarian, clinic name and phone.
Do you have a secondary veterinarian that treats your pet? If so, please list the veterinarian, clinic name and phone.
Who referred you to the Florida Veterinary Behavior Service?
I am the owner(s) of the animal(s) seeking behaivoral medicine treatment from the Florida Veterinary Behavior Service. Behavioral treatment, training and advice when properly maintained after completion can be very helpful in resolving problem behaviors in aniamals. Because each pet is an individaul, no guarantee or assurance can be made as to the results that may be obtained. Animal behavior including aggresion is unpredictable and will remain unpredictable after its treatment. Florida Veterinary Behavior Service cannot promise that the animal's Behavior Service treatment, training or advice will completely eliminate the animal's potential danger to persons or completely control the animal's aggressiveness. Animals should be closely supervised particularly around children and infants and should be controlled at all times including conformance with local ordinances and "leash laws."

I am bringing my pet to this appointment with a full knowledge of these risks and understand and accept the liability that is inherent in owning a pet who has shown aggressive behavior.

I understand that all fees are to be paid at the time of service and accept full responsibility for the charges incurred in the treatment of my pet
Primary Pet Parent's Signature (use your cursor to sign)
SecondaryPet Parent's Signature (use your cursor to sign)
If at least one pet parent listed above will not be physically present at your pet's appointment, please list below the person(s) with whom we are authorized to speak. We cannot speak with anyone about your pet's care outside of the pet parents listed above and your pet's primary care veterinarian without written authorization.
Pet Parent's Signature (use your cursor to sign)

Helpful Hints...
Videos can be very helpful when assessing a pet's behavior patterns. Please send videos of your pet's environment and the behavior problem itself to us at the email above. If the video is too large to send it by email, please upload it to Youtube or Dropbox and send us a link. Do not under any circumstances provoke aggressive behavior in order to get us a video.

Bring all pets that are involved in the problem to the appointment if you can do so safely. If your other pets are not involved directly in the problem for which you are seeking help, it is better for you to leave them at home so that we can concentrate solely on the pet who needs help.

Bring your pet's favorite toys and treats with you to the appointment in case we treat your pets on that day or we can use those items during your pet's appointment.

	N/A	No Reaction	Bite	Tries to Escape	Vocalizes	Screams	Moves Away	Lunges	Grooms	Tries to Bite	Grabs a Toy
Stare at bird
Reach towards bird
Reach over bird's head
Bend over bird
Pet bird
Kiss bird
Roll bird over onto back
Trim nails
Speak to bird in normal tone
Give bird verbal cues
Scold bird verbally
Approach bird while eating
Touch bird while eating
Taking objects (stolen objects)
Taking objects (bird's toys)
Removing object from bird's mouth
Approach when bird is near toy/object
Approach bird while playing with toy
Approach bird while on furniture
Approach/disturb bird while sleeping
Punish physically (hit with hand/object)
Restraining bird
Threatening to hit bird visually
Behavior at vet visits (in exam room)
Enter or leaving room with bird
Someone raises voice at owner in presence of bird
Someone hugs/touches owner in presence of bird

	N/A	No Reaction	Bite	Tries to Escape	Vocalizes	Screams	Moves Away	Lunges	Grooms	Tries to Bite	Grabs a Toy
Guest stares at bird
Guest reaches towards bird
Guest reaches over bird's head
Guest bends over bird
Guest pets bird
Guest kisses bird
Guest rolls bird over onto back
Guest trims nails
Guest speaks to bird in normal tone
Guest gives bird verbal cues
guest scolds bird verbally
Guest approaches bird while eating
Guest touches bird while eating
Guest takes objects (stolen objects)
Guest takes objects (bird's toys)
Guest removes object from bird's mouth
Guest approaches when bird is near toy/object
Guest approaches bird while playing with toy
Guest approaches bird while on furniture
Guest approaches/disturbs bird while sleeping
Guest punishes physically (hit with hand/object)
Guest restrains bird
Guest threatening to hit bird visually
Guest entering or leaving room with bird
Response to baby/toddler guests
Guest raises voice at owner in presence of bird
Guest hugs/touches owner in presence of bird

Florida Veterinary Behavior Service

Florida Veterinary Behavior Service Registration Form and Waiver

Helpful Hints...

Bird Behavioral Questionnaire