First & Last Name

Phone

E-mail

Full Address including postal code

Pet Name(s)

Species & Breed

Date of birth or approx. age

Colour

Gender

Intact or Altered
Intact     Altered

How often does your pet visit the vet? (Annually vs. when ill)

Are they up to date
on vaccines?

Do you administer flea/tick/heartworm prevention?

Are there current health or behavioral concerns?

Any past medical
illnesses?

What diet are you currently feeding your pet?

Current medications?

What are your goals in terms of your pet’s health?

What are you looking for from your Veterinarian?

Is there anything specific you are looking to avoid or change from your previous vet experiences?

What Veterinary hospital did you previously attend so that we can obtain your pet’s medical records?

Are you looking to get pet insurance if you do not already have a policy? Yes     No