Owner Name:
Alternate Owner:
Address:
City/Town:
Postal Code:
E-mail:
Home Phone:
Work:
Cell/Other:
Prefered method of contact:#Home#CellE-mailTextMail
Pets Name:
MaleFemale
Spayed/Neutered
CatDog Other:
Breed:
Birth Date or Approx. Age:
Colour/Making:
Age or Date first obtained:
Previous Veterinarian/Clinic:
Are you a new client?YesNo
If yes, how did you hear about our facility?WebsiteSocial MediaFriend/FamilyDriving By
Other - Please explain:
Who may we thank for recommending us?
General Health:
I would described my pet as:NormalEnergeticQuiet
Water Intake:NormalDecreasedIncreased
Appetite:NormalDecreasedIncreased
Urination:NormalDecreasedIncreasedStraining
Stools:NormalWateryHard/Dry
Recent Coughing/ Sneezing/ Vomiting or Diarrhea:YesNo
If yes, Please explain:
Is your pet currently on any medications?YesNo
If yes, what kind of medication(s)?
Does your pet have any diagnosed conditions?
Does your pet have any of the problems noted below?Stiff JointsDifficulty Getting UpDifficulty With StairsHearing LossVision LossGreasy CoatDandruffPainNone
Husbandry:
Where does your pet sleep and spend most of his/her time?IndoorsOutdoorsMy pet is exclusively kept indoors.
Are there any other pets in the household?YesNo
If so, describe?
Cats #
Dogs #
Other #
Diet:
Do you feed dry kibble, canned food or raw food?
Do you currently soak kibble?YesNo
Where do you buy your pet food?VetPet StoreGrocery StoreHome Cooked
Which brand of food do you feed?
Does your pet receive people food?
Do you use any human or pet supplements?
Dental Hygiene:
Does your pet have bad breath?YesNo
Do you brush your pet’s teeth, if so how often?MonthlyWeeklyDailyNone
Do you use?Dental ChewsGreeniesBully SticksBonesAntlers
Do you use any specialty dental products?MaxiguardHealthymouth
Other
Insurance:
Do you have pet insurance?YesNo
If yes, Who is your provider?
Behaviour Concerns:
Does your pet have any behaviour concerns with:DogsCatsMenChildrenLeashAggression/ReactivityBiting/AggressionHousetrainingCrate Training
Other:
Present Concerns:ItchySores/RashChewing FeetFleasWoundsScootingLameness
Appetite:IncreasedDecreased
Weight GainWeight Loss
Lethargy
CoughingSneezingVomitingDiarrheaConstipation
Onset of signs noted above:GradualSudden
Date of when clinical signs began:
None of the above:
What is the biggest concern for you with your pet, today?