Puppy/Kitten New Patient Questionnaire
Client Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
-
Area Code
Phone Number
Pet's Name
*
Appointment Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Appointment Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Best phone number for your appointment (the veterinarian and hospital staff will use this number to communicate with you throughout your appointment):
*
-
Area Code
Phone Number
When did you obtain your pet?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where did you obtain your pet?
When was your pet's last visit to the veterinarian?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does your pet have any of the following:
Coughing
Sneezing
Vomiting
Diarrhea
None of the above
Other
If your answer indicated an issue in the question above, please describe:
Has your pet had any changes in mobility or activity level? If so, please describe:
Has your pet had any head shaking, scratching, or licking? If so, please describe:
Has your pet had any changes in eating or drinking habits? If so, please describe:
Does your pet have any lumps, bumps or fur loss? If so, please describe:
Please describe your pet's food and treats. How often are you feeding? What amount are you feeding? What brand? Please let us know if there have been any recent changes or additions.
Does your pet go to a grooming, boarding or daycare facility? If so, please describe:
Please check all that apply to your pet's exercise:
100% indoors
Walks on leash
Loose in a fenced yard
Doggy day care
Off leash dog parks
Other
For our kitty friends, does your cat go outside:
Strictly indoors
Indor/Outdoor
Outdoor only
Sometimes goes in the yard
No, but other cat in household goes outside
Do you have Pet Insurance for your pet? If so, carrier's name.
Do you have any concerns for the veterinarian to address? (please be as detailed as possible)
Please note any medications or supplements that your pet is currently taking. Do you need any refills? If yes please list below.
Please note name, strength, dosage and frequency. This includes preventative medication.
Submit
Should be Empty: