New Patient - Dog / Puppy
Client Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Patient Information
Pet's Name
Breed
Sex
Please Select
Intact Male
Intact Female
Neutered Male
Spayed Female
Unknown
Age
exact birthday or approximate age
Weight
approximate weight is fine
Color/Markings
black and tan, white with grey tail, etc.
History
Where did you get your pet?
breeder, pet store, online, etc.
How long have you had your pet?
Does your pet have any past medical history?
Does your pet take any medications or supplements?
Please include the medication strength and frequency of administration.
Please list any other pets in the household:
Vaccines & Parasite Prevention
Rabies Vaccine
When was it given?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DAP (distemper/parvo) Vaccine
When was it given?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Bordetella (kennel cough) Vaccine
When was it given?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Influenza Vaccine
When was it given?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Lepto Vaccine
When was it given?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Lyme Vaccine
When was it given?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Flea & Tick Prevention
Nexgard, Bravecto, Simparica, etc
When was it last given?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Heartworm Prevention?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Heartgard, ProHeart, Sentinel, etc
When was it last given?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Diet
How much do you feed per day? Please list brand, if known.
Lifestyle & Exercise
What is your dog's activity level?
fenced yard, regular walks, daycare, dog sports, etc
Is there anything else about your dog we should know?
fearful, aggressive, doesn't like other dogs, doesn't like men, etc
Uploads
Document & Photo Uploads
Browse Files
Drag and drop files here
Choose a file
Please upload previous veterinary records (if available) and a fun picture of your dog!
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