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Your Pet's Name:
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Your First Name:
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Your Last Name:
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Phone:
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Email:
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How should we contact you?
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Type of Pet:
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Where did you get your pet?
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How long have you owned your pet?
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What prior illness or health issues has your pet had?
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How often do you bathe your pet?
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How often do you brush/comb your pet?
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What type of exercise does your pet receive, and how often?
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How often is your pet around other animals (other than your own)?
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How much time does your pet spend outside?
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Which wildlife is in your area? (Choose all that apply) *
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rabbitssquirrelsskunksraccoonsdeernone
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Does your pet go to: (Choose all that apply) *
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GroomerBoardingPet ShowsPet StoresNone of the Above
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Do you travel with your pet? If so, where else has your pet been?
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Is your pet on pet insurance
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YesNo
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Is Your pet Spayed or Neutered? *
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YesNo
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If you chose NO for the previous questions, do you plan to have it done?
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YesNo
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Do you plan to breed your pet? *
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YesNo
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Does your pet have any drug or vaccine reactions? *
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YesNo
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Does your pet hunt?*
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YesNo
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Is your pet on a preventative for controlling external parasites? (fleas and ticks) *
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YesNo
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Is your pet on a preventative for controlling internal parasites? (heartworm, roundworm, etc) *
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YesNo
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Has your pet been micro-chipped or tattooed? *
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YesNo
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Has your pet ever had professional dental care? *
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YesNo
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Do you understand the health benefits and life extending effects of providing proper dental care for *
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YesNo
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Do you trim your pet's nails at home? *
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YesNo
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Would you like to learn how to trim your pet's nails? *
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YesNo
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Check any of the following that are of concern to you regarding your pet's behavior/health *
(Check all that apply)
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Excessive BarkingHouse TrainingSoiling/Spraying insideProblems around childrenSheddingAnxietyJumpingStraying from homeItching/scratchingOverly rambunctiousBitingClawing or diggingBad breathDestructive BehaviorNone of the Above
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Which of the following are services that you might utilize: *
(Check all that apply)
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Lodging/boarding facilityReferral rewards programWellness plansMassage therapyEvening hoursGroomingDay careProduct trials
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In an emergency where you can not be immediately contacted, you want Companions Animal Hospital to: *
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Provide CPRDo not resuscitate
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