Name *

First

Last

Phone *

Secondary Phone

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is this appointment for a new or exisiting client? *

New Client
Existing Client

Secondary person authorized to make decisions about your pet's healthcare:

First

Last

Please include their phone number here:

Pet Species *

Dog
Cat

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

If yes, please specify their microchip number.

When and where did you get your pet? *

Does your pet have any previously diagnosed health conditions? If so, what? *

Please list any previous veterinary hospitals your pet has visited so we may obtain records. Reason for leaving? *

Please list any other household pets, if applicable. *

Do you feed your pet canned food, dry food, or both? *

Canned
Dry
Both

What medications, supplements, or human products is your pet on? *

Please list name, strength, and frequency of the medications your pet is receiving.

Brand name of pet’s food and the main protein (ie. chicken, beef, fish, etc.): *

How much do you feed your pet? *

Does your pet have any known drug sensitivities or allergies? *

Yes
No

Please specify which sensitivities and/or allergies below. *

Does your pet go outside (cats only)? *

Yes
No

Please provide more information.

Is your pet on a monthly parasite/flea/tick preventative? *

Yes
No

Please specify.

Have you traveled or plan to travel with your pet in the next 12 months? If so, where? *

Have there been any changes in your pet’s appetite (i.e. increased or decreased)? *

Yes
No

Please specify.

Have there been any changes to your pet’s defecation (i.e., increased or decreased frequency, soft or hard stools, straining, vocalizing, blood, etc.)? *

Yes
No

Please specify.

Will you / did you bring a fecal sample for us to screen for intestinal parasites? *

Yes
No

Have there been any changes to your pet’s drinking (i.e., increased or decreased)? *

Yes
No

Please specify.

Have there been any changes to your pet’s urination (i.e., increased or decreased frequency, straining, vocalizing, blood, etc.)? *

Yes
No

Please specify.

Have there been any changes to your pet’s energy level? *

Yes
No

Please specify.

Has your pet recently lost or gained weight? *

Yes
No

Please specify.

Is your pet coughing, sneezing, and/or having nasal or eye discharge? *

Yes
No

Please specify.

Have you noticed your pet having any difficulty breathing? *

Yes
No

Please specify.

Does your pet seem itchy (i.e., scratching, licking paws, head shaking)? *

Yes
No

Please specify.

Have you noticed any limping? *

Yes
No

Please specify.

Does your pet have any new lumps or bumps? *

Yes
No

Please specify.

Do you provide dental care for your pet? *

Yes
No

Please specify.

Does your pet have health insurance? *

Yes
No

Please specify.

Has your pet shown any aggression toward people or other animals? *

Yes
No

Please specify.

Can we post photos of your pet on social media? *

Yes
No

We love to give our patients high-value treats such as peanut butter to enforce positive associations with their visits. If you or someone in your family has food allergies, please list them below.

Please attach any previous medical records or information you like to share.

Click or drag files to this area to upload. You can upload up to 30 files.

Is this appointment for a new or existing patient? *

New Patient
Existing Patient

Pet's Name *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Species (dog, cat, etc.) *

Breed *

When and where did you get your pet? *

Does your pet have any previously diagnosed health conditions? If so, what? *

Please list any previous veterinary hospitals your pet has visited so we may obtain records. Reason for leaving *

Please list any other household pets, if applicable.

Do you feed your pet canned food, dry food, or both? *

Canned
Dry
Both

What medications, supplements, or human products is your pet on? *

Please list name, strength, and frequency of the medications your pet is receiving. *

Do you need any prescriptions filled today? If so, which medication?

Brand name of pet’s food and the main protein (ie. chicken, beef, fish, etc.): *

How much do you feed your pet? *

Does your pet have any known drug sensitivities or allergies? *

Yes
No

Please specify which sensitivities and/or allergies below. *

Does your pet go outside (cats only)? *

Yes
No

Please specify: *

Is your pet on a monthly parasite/flea/tick preventative? *

Yes
No

Please specify: *

Have you traveled or plan to travel with your pet in the next 12 months? If so, where? *

Does your pet have a microchip? *

Yes
No

Please specify: *

Have there been any changes in your pet’s appetite (i.e. increased or decreased)? *

Yes
No

Please specify: *

Have there been any changes to your pet’s defecation (i.e., increased or decreased frequency, soft or hard stools, straining, vocalizing, blood, etc.)? *

Yes
No

Please specify: *

Will you / did you bring a fecal sample for us to screen for intestinal parasites? *

Yes
No

Please specify: *

Have there been any changes to your pet’s drinking (i.e., increased or decreased)? *

Yes
No

Please specify: *

Have there been any changes to your pet’s urination (i.e., increased or decreased frequency, straining, vocalizing, blood, etc.)? *

Yes
No

Please specify: *

Have there been any changes to your pet’s energy level? *

Yes
No

Please specify: *

Has your pet recently lost or gained weight? *

Yes
No

Please specify: *

Is your pet coughing, sneezing, and/or having nasal or eye discharge? *

Yes
No

Please specify: *

Have you noticed your pet having any difficulty breathing? *

Yes
No

Please specify: *

Does your pet seem itchy (i.e., scratching, licking paws, head shaking)? *

Yes
No

Please specify: *

Have you noticed any limping? *

Yes
No

Please specify: *

Does your pet have any new lumps or bumps? *

Yes
No

Please specify: *

Do you provide dental care for your pet? *

Yes
No

Please specify: *

Does your pet have health insurance? *

Yes
No

Please specify: *

Has your pet shown any aggression toward people or other animals? *

Yes
No

Please specify: *

Do you have any other questions or concerns for the doctor? *

What day would you like to visit our hospital? *

What time of the day do you prefer? *

Morning
Afternoon
Evening

What is the reason for your visit? *

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