Name *

First

Last

Email *

Patient Name *

Patient DOB *

Species *

Please specify *

Color *

Gender *

Is your pet microchipped? *

Yes
No

Microchip number

How active is your pet? *

Very active
Moderately active
Not very active

Does your cat go outdoors? *

Yes
No

Does your dog go to the groomer/daycare/boarding/dog parks? *

Yes
No

What are you currently feeding your pet? Please include brand, formula, amount fed and how often, whether canned, dry, or both, as well as any treats, toppers, table scraps, etc. *

Is your pet currently taking medications? *

Yes
No

Please list all medications including medication name, dose, and frequency of administration.

Do you give your pet any dietary supplements, such as fish oil or vitamins? Do you give your pet any natural/herbal remedies? *

Yes
No

Please list all supplements and/or natural herbal remedies including name, dose, and frequency of administration.

Do you give your pet monthly heartworm, intestinal parasite, flea and tick preventives? *

Yes
No

Please list all parasite preventives. Please let us know if you give these seasonally or year-round.

Has your pet ever had a negative reaction to medication or vaccinations? *

Yes
No

Please describe your pet’s reaction in detail, including which vaccination and/or medication caused the reaction.

Is your pet currently being treated for any medical conditions? *

Yes
No

Please describe your pet’s medical condition in detail, as well as response to treatment(s).

How does your pet feel about a visit to the vet? *

Eager and excited
Subdued
Reluctant and fearful

Has your pet shown any avoidance of or dislike of the following? (select all that apply) *

Please explain

What are your pet’s favorite treats?

Does your pet have any food allergies or sensitivities? *

Yes
No

Please list all food items that your pet is allergic to

Is there anything else you would like us to know about your pet’s health or disposition?

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