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Highlands Veterinary Hospital - Canine New Patient Form
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13
Questions
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1
Owner Information
*
This field is required.
Name
Phone
Email
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2
Pet Information
*
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Name of Pet
Estimated Age or Birthdate
Breed
Color
How long have you owned this pet?
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3
Sex
(Circle One)
Male Neutered
Male
Female Spayed
Female
Unknown
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4
Does your dog have a microchip?
YES
NO
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5
Does your pet have any known or suspected food or drug allergies?
YES
NO
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6
If yes, please describe
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7
Previous Medical Conditions
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8
Previous Surgeries or Serious Illnesses (date and description)
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9
Please list any long-term medication(s) and/or supplements pet is taking, please include dosage if known?
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10
Additional concerns or information
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11
Would you like us to request records for this pet from another veterinary facility?
YES
NO
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12
If yes, name of facility
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13
My dog is aggressive toward
Yes
No
Other Animals
Other people
Other Animals
Other people
Yes
No
Yes
No
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