Pet History Form
Client & Pet Information
Please help us locate you in our system by providing the information below.
Client Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet's Name
*
Pet's Age
*
Species
*
Dog
Cat
Other
Breed
*
Sex
*
Male
Female
Spayed/Neutered
*
Yes
No
Photo Consent
We love social media! Do we have permission to share your pet(s)' image and story on social media, our website, and other forms of related media? Your name and personal information will never be shared. Simply check below to authorize this.
*
Yes. I authorize Truesdell Animal Care Hospital and Clinic to share my pet's photo and story.
No. I do not authorize this.
Pet History
Please share your pet's history with us as well as the reason for your visit today.
Please share you pet's history with us:
What does your pet normally eat? Please include brand, amount, and frequency of feeding.
*
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, the strength of the medication, and the frequency in which it is taken.
Does your pet have vomiting or diarrhea?
*
No
Yes
If yes, please share when it started and how often it is happening.
*
Is your pet coughing or sneezing?
*
No
Yes
If yes, please share when it started, how often it is happening, and if there is any nasal discharge and the color.
*
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.
*
Is your pet on heartworm prevention (if warranted)?
*
No
Yes
If yes, please provide details.
*
Does your pet need any refills?
*
No
Yes
If yes, please provide details.
*
What other concerns do you have?
*
If you have not already provided your pet's medical records, and you have them available, please upload them here. These records help us provide the best care for your pet by ensuring we have accurate information about their health history, vaccinations, and any ongoing treatments.
Browse Files
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of
Are you booking a new patient appointment for a second pet?
*
Yes
No
Name
*
Age
*
Species
*
Dog
Cat
Other
Breed
*
Sex
*
Male
Female
Spayed/Neutered
*
Yes
No
If you have not already provided your second pet's medical records, and you have them available, please upload them here. These records help us provide the best care for your pet by ensuring we have accurate information about their health history, vaccinations, and any ongoing treatments.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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