Existing Client with New Pet

Pet Name*
Species*
Breed*
Date of Birth/Age*
Color*
Sex*
Vaccine History - Please indicate the date your pet last received the following recommended vaccines.
FVRCP*
Leukemia*
Rabies*
DAPP*
Lepto*
Bordetella*
Rabies*
Cats Has your cat had a Leukemia or FIV blood test, if so what date?

MonthDayYear
Date
Dogs Has your dog had a heartworm blood test, if so what date?

MonthDayYear
Date
Has your pet had a fecal test, if so what date?

MonthDayYear
Date
How many hours a day does your pet spend outdoors?
What type of flea and heart worm preventative are you currently using? Enter none if your pet is not preventatives?
Does your pet have any prior medical or surgical history? Please explain.
Is your pet currently on any medications? (Please indicate the dosage and duration)
Does your pet have any drug allergies? Please explain.
Any concerns regarding your pet's behavior? (i.e. housebreaking/litterbox training, digging, barking, inappropriate chewing)
What does your pet eat? (Please indicate how much and how often)
Does your pet receive any treats or extras? (Please explain)
Thank you for allowing our hospital the opportunity to care for your pet!
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