LAH - Pet History Form
Please help us locate you in our system by providing the information below
Client & Pet Information
Client Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet's Name
*
Species
*
Dog
Cat
Other
Pet's Age
*
Pet History
Please share your pet's history with us as well as the reason for your visit today.
What brings you in today?
*
What does your pet normally eat?
*
Is your pet current on vaccinations?
*
Yes
No
If no, please provide details.
*
Is your pet currently taking any medications? If yes, please let us know what medications they are taking.
Is your pet experiencing vomiting or diarrhea?
*
No
Yes
If yes, please provide details.
*
Is your pet coughing or sneezing?
*
No
Yes
If yes, please provide details.
*
Is your pet urinating normally?
*
Yes
No
If no, please provide details.
*
Is your pet drinking more water than normal?
*
No
Yes
If yes, please provide details.
*
Does your pet get flea/tick preventative?
*
No
Yes
If yes, please provide details on brand/frequency.
*
Is your pet on heartworm prevention (if warranted)?
*
No
Yes
If yes, please provide details on brand/frequency.
*
What other concerns do you have?
*
Please provide the best way to contact you after your pet's exam. We will call to discuss exam findings as well as collect payment over the phone prior to pick up.
*
Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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