The required sections have a red * asterisk.
*Address: (Street, City, State, Zip)
Alternative Phone Number:
*What is your pet coming in for?
If your pet is receiving their Rabies vaccine at this visit, will you be needing a County License for
your Rabies tag?
Is appetite and/or fluid intake normal?
Has their activity level decreased/increased?
Is urination normal?
Any sneezing, coughing, vomiting, or diarrhea? How long and how often have these symptoms
been going on?
Have you noticed any itching or scratching?
Is your pet shaking their head or scratching at their ears?
Have you noticed any lumps or bumps we have not checked before? If so please describe size and
Any history of seizures?
What medications or supplements does your pet take and what is the dosage you are currently
Is your pet on flea and/or heartworm prevention? If yes, what brand is it and do you need a refill
Your pet's medical needs change as their bodies age. To ensure we are monitoring for different
diseases and conditions that can affect your pet, we recommend twice yearly bloodwork. Would you
like this performed today?
Does your pet have a microchip?
Do you have pet insurance and if so, what company is it with? (If a claim form needs to be
completed please bring this with you)
How many cats do you have in your household? Are they indoors or outdoors?
What food do you feed your pet and how much?
If this is your first visit or you have seen another Veterinarian since your last visit, please provide
the name and phone number of the clinic to get previous records from.
Do you have any other concerns?