Animal Care Clinic - Client Information

Client Information

Owner(s) Name*

First NameLast Name

Phone*

Email Address*

example@example.com

Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Vehicle Description

Parking spot #

Patient Information Pet #1

General Information

Pet Name

Breed/Color

Date of Birth/Age

Sex/Spayed/Neutered?

Any previous serious illness or injuries?

Any reaction/intolerance to vaccinations or medications?

Special diets/current medications/supplements?

Is peanut butter ok for us to use as a treat?

How long have you had the pet?

What age were they when they joined the family?

Vaccines

Date of Last Vaccination

Rabies vaccine(Dog/Cat)

Lepto vaccine(Dog)

Dapp/Parvovaccine (Dog)

Lyme (Dog)

Bordetella- Kennel cough (Dog)

FVRCP- Feline Respiratory vaccine (Cat)

Feline Leukemia (Cat)

Any allergies to vaccinations or medications

Feeding/Nutrition

How do you feel about their current weight?

Special diets/ current medications

What brand of food are you feeding?

How much?

Drinking/appetite?

GI

Vomiting/Diarrhea?

Change in stool such as color or appearance?

Eating/Drinking normally?

Sensitive stomach?

Parasites

Which flea prevention product are you currently using?

Which heart worm prevention product are you currently using?

Did you bring a fecal sample today?

Have you seen any fleas/ticks or worms?

Oral

How is their breath?

Do they have any trouble eating?

Skin

Any skin/hair problems?

Do they scratch or scoot?

Are they licking/ scratching or rubbing anywhere?

Ear

How is their hearing?

Odor or sensitive scratching/rubbing ears?

Eye

Eye discharge?

Is it clear or is there a odor?

Red/white eyes?

Are the squinting?

How is vision?

Urinary

Any accidents or dribbling urine when laying down?

Is there an increase in the frequency or amount?

Are they straining to urinate?

Respiratory

Coughing, sneezing, nasal discharge color? (Please describe)

Mobility/Activity

How much time do they spend outside?

How long is their walks?

How is their activity level?

How are they on stairs, getting in and out of the car, jumping on furniture?

Behavior

Behavior concerns? Separation anxiety, storm fear, aggressive?

Cat- Using the litter box all of the times? For both urine and stool?

Cat- Environment enrichment, toys tower, hiding spots?

Other

History of seizures?

Do you want to add more pets?*

YesNo

Patient Information Pet #2

General Information

Pet Name

Breed/Color

Date of Birth/Age

Sex/Spayed/Neutered?

Any previous serious illness or injuries?

Any reaction/intolerance to vaccinations or medications?

Special diets/current medications/supplements?

Is peanut butter ok for us to use as a treat?

How long have you had the pet?

What age were they when they joined the family?

Vaccines

Date of Last Vaccination

Rabies vaccine(Dog/Cat)

Lepto vaccine(Dog)

Dapp/Parvovaccine (Dog)

Lyme (Dog)

Bordetella- Kennel cough (Dog)

FVRCP- Feline Respiratory vaccine (Cat)

Feline Leukemia (Cat)

Any allergies to vaccinations or medications

Feeding/Nutrition

How do you feel about their current weight?

Special diets/ current medications

What brand of food are you feeding?

How much?

Drinking/appetite?

GI

Vomiting/Diarrhea?

Change in stool such as color or appearance?

Eating/Drinking normally?

Sensitive stomach?

Parasites

Which flea prevention product are you currently using?

Which heart worm prevention product are you currently using?

Did you bring a fecal sample today?

Have you seen any fleas/ticks or worms?

Oral

How is their breath?

Do they have any trouble eating?

Skin

Any skin/hair problems?

Do they scratch or scoot?

Are they licking/ scratching or rubbing anywhere?

Ear

How is their hearing?

Odor or sensitive scratching/rubbing ears?

Eye

Eye discharge?

Is it clear or is there a odor?

Red/white eyes?

Are the squinting?

How is vision?

Urinary

Any accidents or dribbling urine when laying down?

Is there an increase in the frequency or amount?

Are they straining to urinate?

Respiratory

Coughing, sneezing, nasal discharge color? (Please describe)

Mobility/Activity

How much time do they spend outside?

How long is their walks?

How is their activity level?

How are they on stairs, getting in and out of the car, jumping on furniture?

Behavior

Behavior concerns? Separation anxiety, storm fear, aggressive?

Cat- Using the litter box all of the times? For both urine and stool?

Cat- Environment enrichment, toys tower, hiding spots?

Other

History of seizures?

Do you want to add more pets?*

YesNo

Patient Information Pet #3

General Information

Pet Name

Breed/Color

Date of Birth/Age

Sex/Spayed/Neutered?

Any previous serious illness or injuries?

Any reaction/intolerance to vaccinations or medications?

Special diets/current medications/supplements?

Is peanut butter ok for us to use as a treat?

How long have you had the pet?

What age were they when they joined the family?

Vaccines

Date of Last Vaccination

Rabies vaccine(Dog/Cat)

Lepto vaccine(Dog)

Dapp/Parvovaccine (Dog)

Lyme (Dog)

Bordetella- Kennel cough (Dog)

FVRCP- Feline Respiratory vaccine (Cat)

Feline Leukemia (Cat)

Any allergies to vaccinations or medications

Feeding/Nutrition

How do you feel about their current weight?

Special diets/ current medications

What brand of food are you feeding?

How much?

Drinking/appetite?

GI

Vomiting/Diarrhea?

Change in stool such as color or appearance?

Eating/Drinking normally?

Sensitive stomach?

Parasites

Which flea prevention product are you currently using?

Which heart worm prevention product are you currently using?

Did you bring a fecal sample today?

Have you seen any fleas/ticks or worms?

Oral

How is their breath?

Do they have any trouble eating?

Skin

Any skin/hair problems?

Do they scratch or scoot?

Are they licking/ scratching or rubbing anywhere?

Ear

How is their hearing?

Odor or sensitive scratching/rubbing ears?

Eye

Eye discharge?

Is it clear or is there a odor?

Red/white eyes?

Are the squinting?

How is vision?

Urinary

Any accidents or dribbling urine when laying down?

Is there an increase in the frequency or amount?

Are they straining to urinate?

Respiratory

Coughing, sneezing, nasal discharge color? (Please describe)

Mobility/Activity

How much time do they spend outside?

How long is their walks?

How is their activity level?

How are they on stairs, getting in and out of the car, jumping on furniture?

Behavior

Behavior concerns? Separation anxiety, storm fear, aggressive?

Cat- Using the litter box all of the times? For both urine and stool?

Cat- Environment enrichment, toys tower, hiding spots?

Other

History of seizures?