DATE:_____/_____/_____

PETS NAME:__________________________
CANINE:______

CLIENTS NAME:__________________________________

FELINE:______

BREED:______________________
MALE:______

NEUTERED: YES:___ NO:___

DATE OF BIRTH:_____/_____/_____

OTHER:_______

COLOR:______________________
FEMALE:______

SPAYED: YES:___ NO:___

APPROXIMATE AGE: YEARS:_____ MONTHS:_____ WEEKS:_____

DO YOU HAVE PET INSURANCE? YES:_____ NO:_____ WOULD YOU LIKE TO LEARN MORE ABOUT
PET INSURANCE? YES:_____ NO:_____
1.) WHO HAS BEEN YOU PETS PRIOR VETERINARIAN? (So we may request records):
_________________________________________________________________________________________________
PRIOR VETERINARIANS PHONE #:(______)________-______________
2.) THE APPROXIMATE DATES OF THE LAST VACCINATIONS:_______/_______/_______
3.) THE APPROXIMATE DATE OF THE LAST HEARTWORM TEST (K-9):_______/_______/_______
4.) IS YOUR PET ON HEARTWORM PREVENTIVE? YES:_____ NO:_____
5.) DOES YOUR PET HAVE ANY KNOWN ALLERGIES (DRUG, FOOD, INSECT)? YES:_____ NO:_____
PLEASE NAME:___________________________________________________________________________________
__________________________________________________________________________________________________
6.) IS THERE ANY MEDICAL OR SURGICAL HISTORY WE SHOULD KNOW ABOUT? ANY TRAUMA OR
CHRONIC CONDITIONS? PLEASE DESCRIBE AND GIVE APPROXIMATE DATES:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
7.) IS THERE ANY SPECIAL LIKES OR DISLILKES YOUR PET HAS? (Such as tries to bite when temperature
taken) YES:_____ NO:_____
IF YES PLEASE DESCRIBE:__________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
8.) DO YOU (OR YOUR PET) PREFER PILLS OR LIQUID MEDICATIONS?
PILLS:_____
LIQUID:_____
TELL ME ABOUT TRANSDERMAL MEDICATIONS:_________________________________________________
__________________________________________________________________________________________________
9.) ANYTHING ELSE YOU WOULD LIKE US TO KNOW BEFORE EXAMINING OR TREATING YOUR PET?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________