PERSONAL INFORMATION

Today's Date:

Owner's Name: [*]

Spouse's Name:

Full Address (Include Street, Street#, Apt# if Applicable, City, State and ZIP):[*]

Phone (Home):

Phone (Work):[*]

Cell:[*]

Spouse's Phone (Work):

Spouse's Cell:

Email: [*]

We enjoy taking pictures & videos of our patients & their families. By checking this box, you authorize the use of such photos & videos for advertising & web use

How did you hear about us?
NONE SELECTED Friend or Family Referral Phone Book Internet Other

If you selected friend or family, can you kindly provide name, address and phone number?

If you selected other, can you kindly explain?

PET INFORMATION

Pet's Name:

Breed:

Male / Female?
NONE SELECTED Male Female

Color:

Birthday (Month / Day / Year):

Spay / neutered?
NONE SELECTED Yes No

Date of Last Vaccines?:

Where?:

To provide you and your pet with the best possible care and customize your pet’s health needs, we have a few specific medical questions:

Does your pet have any of the following symptoms?:
Loose Stools
Vomiting
Coughing
Heavy Breathing
Sneezing
Eye Discharge
Itching
Hair Loss
Fleas or Ticks
Skin Growths
Bad Breath

Does your pet exhibit any of the following behaviors?:
Unwanted Aggression
Excesive Barking
Marking
House-soiling
Other

Please explain if you selected "Other":

Does your pet drink more water than a year ago?
NONE SELECTED Yes No

Have you noticed changes in pet’s sleep habits?
NONE SELECTED Yes No

Does your pet have trouble with stairs or stiffness?
NONE SELECTED Yes No

What food is your pet on?

Brand?

How much do you feed your pet? (Cups)

How Often?

Do you give your pets any supplements?
NONE SELECTED Yes No

Do you give your pets any vitamins?
NONE SELECTED Yes No

Do you brush your pet’s teeth?
NONE SELECTED Yes No

Is your pet currently protected from heartworms?
NONE SELECTED Yes No

Is your pet currently on a flea and tick preventative?
NONE SELECTED Yes No

How often do you bathe your pet or trim nails?

Does your pet have a microchip?
NONE SELECTED Yes No

If yes, Microchip Number:

Any other concerns you may have about your pet?

How would you prefer to pay for your services?
NONE SELECTED Cash Check Visa/MasterCard/Discover Care Credit

ALL FEES ARE DUE WHEN SERVICES ARE RENDERED. THANK YOU FOR YOUR COOPERATION IN THIS MATTER. CREDIT CARDS OR CARE CREDIT ARE ACCEPTED FOR THOSE INTERESTED IN DELAYING PAYMENT.