RRVH Puppy/Kitten New Pet Visit

Puppy/Kitten New Patient Questionnaire
Client Name*

First NameLast Name
Email
example@example.com
Phone Number*

Area CodePhone Number
Pet's Name*
Appointment Date

MonthDayYear
Date
Appointment Time

:HourMinutesAM/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 CodePhone Number
When did you obtain your pet?

MonthDayYear
Date
Where did you obtain your pet?
When was your pet's last visit to the veterinarian?

MonthDayYear
Date
Does your pet have any of the following:

CoughingSneezingVomitingDiarrheaNone of the aboveOther
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% indoorsWalks on leashLoose in a fenced yardDoggy day careOff leash dog parksOther
For our kitty friends, does your cat go outside:

Strictly indoorsIndor/OutdoorOutdoor onlySometimes goes in the yardNo, 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.
Should be Empty: