* Please note: Filling out this form does NOT mean you are scheduling an appointment. Client name:* First Last Spouse or other responsible party:* Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Cell:Email* Pet owner’s date of birth* MM slash DD slash YYYY Pets Name* Animal* Age* Sex* Breed* Primary Reason for Today’s Visit:* Date* MM slash DD slash YYYY Would you like your pet's nails trimmed today?* Yes No Stay for a bath?* Yes No For Cats Only: Indoor Outdoor Both Does your pet have a microchip?* Yes No Do you feed any RAW MEAT DIET?* Yes No Give table/people food?* Yes No Type of food* Canned Dry Both Food Brand Is your pet taking any long term prescriptions, over the counter drugs or herbal remedies?* Yes No If yes, please specify:* Does your pet have any known allergies to ANY medications?* Yes No Does your pet have any chronic medical problems?* Yes No Is your pet on flea control?* Yes No If yes, what kind?* Do you need any refills?* Yes No Describe any dental home care:* Does your pet show any of the following symptoms? Bad breath or body odor? Any vomiting or diarrhea? VOMIT more then 2 times a month? Coughing, sneezing or wheezing? Scooting on rear end? Change in bowel movements/urination? Weight loss/gain? Change in behavior? Lameness/Stiffness? Excessive Itching/scratching of ears / skin? Lumps/Bumps? Unusual Discharge of eyes / nose / other? Change in water/food intake? We like to use (positive) cute pictures of our patients on our websites and displays when we catch them, but we do need your permission:* I authorize the use of my pet’s images for social media, displays, newsletters or website.Signature
