New Puppy/Dog Intake Form
Tsawwassen Animal Hospital
Today's Date
-
Month
-
Day
Year
Date
If you already have an appointment scheduled, please enter the date of your appointment below. (Please note, this form cannot be used to schedule an appointment)
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Email
example@example.com
Co-Owner Name
First Name
Last Name
Co-Owner Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet's Name
Breed
Colour
Sex
Birth Date
-
Month
-
Day
Year
Date
Is your dog spayed or neutered?
Yes
No
Length of time you have owned your dog
Name of previous veterinary clinic
Do we have your permission to call for previous veterinary records?
Yes
No
Do you have health insurance for your dog?
Where did you obtain your dog?
Please list previous vaccination types and dates administered
Vaccination History
Rows
Date Last Given
DHPP
Bordetella
Rabies
Leptospirosis
Lyme
Date of last deworming
What diet are you feeding your dog
Diet- please select all that apply
Dry
Canned
People food/table scraps
How many feedings per day?
Dog's Environment
House/Yard
Apartment
Acreage/Off Leash Parks
Do you have other pets?
Yes
No
If yes, please least name and species
Is your dog currently taking medication?
Yes
No
If yes, please list medication name, dose and frequency
Do you give your dog supplements or vitamins?
Yes
No
If yes, please list below
I feel my dog's weight is
Too Low
Ideal
Too High
Do you brush your dog's teeth?
Yes
No
Do you travel with your dog?
Yes
No
Do you board your dog at a boarding facility?
Yes
No
Does/will your dog go to dog training or doggie day care?
Yes
No
Haven't decided yet
Is there anything else you'd like us to know about your dog?
Submit
Should be Empty: