Your Pet's History Report

Driver's License # (If you will be paying by check)

Co-Owner Name (first & last):

Co-Owner Phone Number:

Patient Information:

Pet's Name*

Age / DOB*

Species*

Cat

Dog

Breed*

Color/Markings

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Weight

Pet insurance: Yes or no? If yes, please list name of provider:

Pet #2

Pet's Name

Age/DOB

Species

Breed

Color/Markings

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Your Pet's History Report. Please complete the following about your pet’s health:

Do you use a heartworm preventative? If yes, please list the name and date last given:*

Do you use a flea/tick preventative?*

Yes

Have you seen fleas or ticks on your pet?*

Yes

What brand of food do you feed your pet? How much and how often?*

Do you provide dental care for your pet? If yes, please explain:*

Have you noticed any lumps or bumps on your pet? If yes, please explain:*

Have you noticed any skin or coat problems on your pet? If yes, please explain:*

Please check if you have noticed any of the following:

Coughing or labored breathing

Limping

Tiredness or sluggishness

Diarrhea

Increased Thirst

Increased Urination

Constipation

Vomiting

Increase/Decrease of weight

Other

Please list any health issues you would like to discuss with the veterinarian.

How did you hear about us?*

Internet/Website

Personal referral

Social Media

Newspaper Ad

Roadside Billboard

Penny Saver

Yellow Pages

Other

If you were referred by a client, what is their name?

I understand that my pet’s picture may be used on social media sites.

YES, you can use my pet's photo.

NO, do not use my pet's photo.