Burlington Vet - Patient Information

1
Pets Name
Date of Birth (or approximate age)
Please Select
Please Select
Male
Neutered Male
Female
Spayed Female
Sex
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Please Select
Canine
Feline
Species
Breed
Color/Markings
2
Email
example@example.com
3
Identification
Microchip: (brand & #)
Tattoo: (location/#)
4
How long have you had your pet?
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Please Select
Breeder
Shelter/Rescue
Friend/neighbor
Pet Store
Stray
Acquired from
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Please Select
Grooming
Boarding
Dog Parks
Daycare
Show
Agility
Breeding
Does your Pet participate in any of the following?
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Please Select
Strictly Indoors
Indoor/Outdoor
For Felines only
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Please Select
No
Yes
Declawed
When was the last time your pet has visited a veterinarian?
5
Name of Hospital/Veterinarian(s)
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Please Select
No, I prefer that you do not contact them
Yes
Do we have permission to contact previous Veterinary Hospital(s) in regards to your pet‛s medical history?
6
Any surgeries or medical conditions your pet has been treated for in the past? Please list below
7
Please list any medication, vitamins, heartworm or flea/tick prevention your pet is taking
8
Please Select
Please Select
No
Yes
Has your pet ever had any seizures?
when and how often?
9
Is your pet allergic to anything that you are aware of ? Please list below
Medications
Food
Other
10
Feeding
What brand?
How much?
How often?
11
Please list any concerns you may have about your pet or any additional information that may be important to your pets health care
12
Owner‛s Signature * This field is required.
Clear
13
Date * This field is required.
Date
Year
Month
Day
Should be Empty: