First Name:
Last Name:
Spouse/Alternate owner:
Address:
City/Town:
Postal Code:
E-mail:
Home Phone:
Work:
Cell/Other:
Preferred method of contact:#Home#CellE-mailTextMail
Referring Veterinarian/Clinic:
Pet's Name:
Status:MaleFemale
SpayedNeuteredunaltered
Species:
Breed:
Birth Date or Approx. Age:
Colour/Marking:
Does your pet have problem withother dogscatsmenchildrenchewingbiting/aggressionhousetrainingOther
Other - Please explain:
Has your pet ever growled or bitten (including in-hospital)?YesNo
General Health:
I would describe my pet as:NormalHyperactiveLethargic
Water intake:NormalDecreasedIncreased
Appetite:NormalDecreasedIncreased
Urination:NormalDecreasedIncreased
Stools:NormalWateryHard/Dry
Coughing/Sneezing/Breathing Difficulty:YesNo
If yes, Please explain:
Is your pet currently on any medications?YesNo
If yes, what medication(s)?
Diet:
Do you feed dry kibble or canned food?
Do you currently soak kibble?YesNo
What brand of food do you feed?
Does your pet receive people food?
What is your current method of dental hygiene?Toothpaste/Brushing TeethDental Chews/GreeniesWater AdditivePlaque OffMaxiguard WipesNothing
If you brush your pet's teeth, How often?MonthlyWeeklyDailyNeverRarely
Do you use any specialty dental products?MaxiguardChlorhexidine RinseToothpasteNothing
Other:
Does your pet have bad breath?YesNoDon't Know
Do you have pet insurance?YesNo
If yes, Who is your provider?
I already have an appointment booked.I would like to be contacted to arrange an appointment.