PetInfo

Pet's Name:

Owner Name: First Name * Last Name *

Date of Birth/Approximate Age:

Species: *

Breed:

Color/Markings:

Sex:

Female Spayed Female Male Neutered Male

Where and when did pet come to be in your family?:

Are there other pets in your household?:

Yes No

If so, please indicate quantity:

Dogs: # Cats: #

Birds: # Reptiles:#

Other:

Please indicate quantity.

Are they doing well?:

Yes No

Are they up to date on preventative care?:

Yes No

Would you like to add your other pets to our files?:

Yes No

Reason for today's visit?:

Tell us why you're visiting us today:

We are Fear Free Certified and want to make this visit as easy as possible for all pets.

Is your pet fearful, anxious, or aggressive during veterinary visits?:

Yes No

Would you be interested in doing an initial Fear Free Examination (which is complimentary) for your pet's first visit instead?:

Yes No

This allows your pet to have a happy first impression without any procedures it may be anxious about. It also allows our doctor to determine if herbal or medicinal help is warranted to give your pet prior to next the wellness visit in which procedures will be done.

Please call us within 48 hours of your appointment time if you would like to do a Fear Free Visit, or if you would like more details.

How is your pet doing? (Please check all that apply)

Energy Level:

Normal Good Poor

Current Appetite:

Normal Good Poor Decreased Increased

Drinking:

Normal Increased Decreased

Urination:

Normal Increased Decreased

Bowel Movements:

Normal Increased Decreased Diarrhea Color Change Other

Has your pet been...?:

Vomiting Coughing Limping Sneezing Seizures Discharge from eyes Discharge from nose NONE

If so, please describe:

Skin Problems...?:

If so, location:

Ear Problems...?:

Itching Redness Discharge Head Tilt Pawing/Shaking Odor NONE

Other Behavior Problems...?:

House Soiling Inappropriate Chewing Excessive Barking Destructive Aggression Fearful at Home NONE Other

Tell us about your pet's activities

How much time does your pet spend outdoors, other than to relieve themselves if canine?:

100% 75% 50% 25% 0%

If pet goes outside, where does it go?:

Backyard Around the Neighborhood Parks Lakes/Ponds Spend time in the country Other

What plant(s) does your pet have access to? This is important to know because some can be toxic to your pet.

Ex: Sago Palms, Palm Trees, Lilies, etc..

Does your pet get professionally groomed?:

Yes No

Does your pet board in a kennel facility?:

Yes No

Nutrition

What kind of food do you feed your pet?
Please specify brand/types and how often of each:

DRY BRAND
Brand/Type: name   How often/much:   cups / ounces

CANNED BRAND
Brand/Type: name   How often/much:  can size / portion

RAW BRAND
Brand/Type: name   How often/much:  ounces / pounds

TREATS
Brand/Type: name   How often/much: amount per day

People food? How often? (Please specify):

Animal Bones? How often? (Please specify type such a raw meaty bones):

Current or Previous Medical Conditions

Does your pet have any allergies/sensitivities to food, medications, vaccines, etc?:

Yes No

If Yes, please describe:

Has your pet had any surgeries or anesthesia procedures?:

Yes No

If Yes, Please describe:

Did your pet have any problems/complications with anesthesia?:

Yes No

If Yes, Please describe:

Medications

List all medications, suppliments, and herbals your pet is currently receiving (name and dosage).

Brand/Type: name Dose/amount per day: amount .

Additional Medication Info:

Vaccination and Medical History

Hospital/Clinic Name: name* Phone: number* .

Email: Email

*Many Hospitals/Clinics require owner release of pet medical records.

Heartworm Preventative

Is your pet currently taking heartworm preventative?:

Yes No Pet has NEVER been on heartworm prevention.

If Yes, what brand?: blanks . Date given: blank .

If No, what brand?: blanks . Approximate last date given: blank .

Flea/Tick Control Products

Have you seen any fleas or ticks?:

Yes No

Flea/Tick control products used?: Name . Date given: MM/DD/YYYY .

In Home?: Name . Date treated: MM/DD/YYYY .

In Yard?: Name . Date treated: MM/DD/YYYY .

Have you seen feral cats in your community?:

Yes No

Is your dog or cat active in woody areas, tall grassy areas, or areas with leafy ground cover? (including bayou and other trails in the area, parks/campgrounds/etc):

Yes No

Have you seen or removed ticks from your pets or a family member recently?:

Yes No

Has your pet been routinely tested for tick borne diseases or been found to be positive?:

Yes No

Dental Care

Do you brush your pet's teeth?:

Yes No

Other dental care methods?:

Date of last dental cleaning:

Identification

Does your pet have a name tag?:

Yes No

Microchip Identification?:

Yes No

We believe in all pets being microchipped. Would you like more information on this?:

Yes No

Pet Insurance

Is your pet covered under any Pet Insurance?:

Yes No

If yes, what is the name of your Pet Insurance Provider?:

If no, would you like information on Veterinary Pet Insurance?:

Yes No

Is there anything else you would like to mention or have concerns about today?

We gladly provide a written Health Care Plan with associated professional fees. This will be important to you since ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. In cases of extensive medical or surgical procedures, when full payment may be difficult at discharge, we accept Visa, American Express, Discover, or Care Credit.

PET INFORMATION