New Client Canine Health History Latham Animal Hospital

New Client Canine Health History Latham Animal Hospital
DateTime
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should another person be listed on account?

First NameLast Name
Phone Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Email
example@example.com
Client health screening: please complete this survey prior to coming to our hospitals to inform us of any risk to our team members. We do require face coverings for all clients coming within six feet of our employees.
Please check all that apply so we may take appropriate precautions.
Pet's name
Pet's date of birth

MonthDayYear
My pet:
Breed:
Sex:
Is your dog on any prescription or homeopathic medications or supplements?
I hereby authorize the veterinary hospital to examine, prescribe, and treat my pet. I assume financial responsibility for all charges accrued through the treatment of my pets. I understand that payment must be made at the time of treatment and that I may be asked for a deposit for emergency and surgical treament.
Signature
My dog's story
My dog joined my family as
My dog lives in a/an
My dog lives with
To me, my dog is: (please check all that apply)
With people, my dog
With other dogs, my dog
With cats, my dog thinks
Bringing my dog to the vet is
Do you have anything to add about your pet's story?
My dog's exercise and nutrition assessment
My dog is
When my dog is "home alone". s/he is
My dog is outside
For exercise, my dog (check all that apply):
For primary nutrition, my dog eats (check all that apply):
My dog eats
When it comes to treats, my dog has
For treats, I use (check all that apply)
Is there anything more you would like to add or ask about your dog's exercise and nutrition?
Environmental Risks
My dog and I like to visit (check all that apply)
My dog and I like to travel
When we are outside, my dog
For heartworm prevention, my dog
For fleas and ticks, I use
Does your dog have any special environmental risks that we should know about?
Health Survey:
Let's start with their mouth:
What about your dog's mouth? (check all that apply)
What dental care do you do at home? (check all that apply)
And their eyes:
My dog's eyes (check all that apply)
Ears:
My dog's ears (check all that apply):
Heart and Lungs:
My dog (check all that apply)
Skin and Body:
My dog's coat and body (check all that apply)
Mobility and movement:
My dog(check all that apply)
Weight and appetite:
My dog (check all that apply)
GI system:
My dog (check all that apply)
Behavior and Cognition:
My dog (check all that apply)
Have there been other health changes that we should be aware of?
What are the primary concerns that need to be addressed at today's visit?
Thank you so much for completing this survey. We appreciate your deep knowledge of your pet, and this helps us partner more effectively with you to develop the best preventive care plan tailored to meet your pet's and your family's needs.
Should be Empty:

New Client Canine Health History Latham Animal Hospital

My dog's story

My dog's exercise and nutrition assessment

Environmental Risks

Health Survey:

Let's start with their mouth:

And their eyes:

Ears:

Heart and Lungs:

Skin and Body:

Mobility and movement:

Weight and appetite:

GI system:

Behavior and Cognition: