Pet Information Form

Pet Information Form

New Baltimore Animal Hospital
Client's Name: *

First Name Last Name
Pet's Name: *
Species: *

Cat Dog Other
Gender: *

Male Neutered Male Female Spayed Female
Breed: *
Color: *
Date of Birth or estimated if uncertain: *

Month Day Year
Date
Is your pet microchipped? *

Yes No Uncertain
If yes, chip number here:
If your pet has been seen at another veterinary office we can receive records from, please list: *
Vaccine Status: *

Up to date, please email a copy to: nbah@comcast.net Need some vaccines Unvaccinated Uncertain
Are you a first-time pet owner? *

Yes No
Where did you get your pet? *

Shelter/Rescue organization Breeder Stray Previous feral neighborhood cat/dog
My pet is currently on the following medications, (including vitamins and supplements: *
My pet's current diet, including treats is: *
Does your pet have any medical conditions, or medical history we should be aware of? *
List any major surgeries or illnesses: *
Best description of your pet during a nail trim: *

Precious love bug Has his/her moments Little troublesome Definitely need to muzzle Uncertain
Has your pet required a muzzle for certain procedures? *

Yes No N/A
Does your pet suffer from separation or thunderstorm anxiety? *

Yes No Uncertain, but I'm willing to discuss this with my doctor at the appointment.
Has your dog ever had any formal obedience training? *

Yes No N/A
Does your dog have any problems or issues in the following areas: *

Mouthing Barking Jumping Chewing Housetraining/marking Aggression Raiding Garbage can
Should be Empty: