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Highlands Veterinary Hospital - New Feline Patient
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16
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
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3
How long have you owned this pet?
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4
Hair Coat Length (circle one)
*
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Short
Medium
Long
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5
Sex (circle one)
*
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Male Neutered
Male
Female Spayed
Female
Unknown
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6
Does your cat have a microchip?
YES
NO
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7
Does your cat live (circle one)?
Inside Only
Outside Only
Inside & Outside
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8
Does your pet have any known or suspected food or drug allergies?
*
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Yes
No
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9
If yes, please describe
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10
Previous Medical Conditions
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11
Previous Surgeries or Serious Illnesses (date and description)
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12
Please list any long-term medication(s) and/or supplements pet is taking, please include dosage if known?
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13
Additional concerns or information
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14
Would you like us to request records for this pet from another veterinary facility?
Yes
No
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15
If yes, name of facility
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16
My cat is aggressive toward
Yes
No
Other Animals
Row 0, Column 0
Row 0, Column 1
Other people
Row 1, Column 0
Row 1, Column 1
Other Animals
Other people
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
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