Patient Information Form

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Patient Information
Pet’s Name: ________________________________________
Species (circle one): Dog
Cat
Other
Male
or Female
/ Spayed
or Neutered
Date spayed or neutered _________________________________
Breed:___________________________________________ Birthday/age: ______________________________________
Color/description:_______________________________________ Microchip ID: ________________________________
Date Obtained: ______________________ Where did you obtain your pet? ______________________________________
Have you owned pets previously? Yes
No
Are there other pets in the home? Yes
No
If there are other pets Please indicate the species and number of each: Dogs (#) _______ Cats (#) _______
Birds (#) _______ Reptiles (#) _______ Other (Species & #) ________________________________________________
On average, how much time does your pet spend outside? _____ (hours). Do any other pets go outside? _______________
What do you feed your pet? How much per day? __________________________________________________________
Any vitamins or supplements? How much per day? _________________________________________________________
Any Medications? What dosage? For how long? ___________________________________________________________
Has your pet ever had a reaction or a medication, vaccination or other product? If so what and when? _________________
___________________________________________________________________________________________________
Patient Information
Pet’s Name: ________________________________________
Species (circle one): Dog
Cat
Other
Male
or Female
/ Spayed
or Neutered
Date spayed or neutered _________________________________
Breed:___________________________________________ Birthday/age: ______________________________________
Color/description:_______________________________________ Microchip ID: ________________________________
Date Obtained: ______________________ Where did you obtain your pet? ______________________________________
Have you owned pets previously? Yes
No
Are there other pets in the home? Yes
No
If there are other pets Please indicate the species and number of each: Dogs (#) _______ Cats (#) _______
Birds (#) _______ Reptiles (#) _______ Other (Species & #) ________________________________________________
On average, how much time does your pet spend outside? _____ (hours). Do any other pets go outside? _______________
What do you feed your pet? How much per day? __________________________________________________________
Any vitamins or supplements? How much per day? _________________________________________________________
Any Medications? What dosage? For how long? ___________________________________________________________
Has your pet ever had a reaction or a medication, vaccination or other product? If so what and when? _________________
___________________________________________________________________________________________________

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