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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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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 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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How often is your pet around other animals that are not your own? (which species)
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Do you travel with your pet? If so, where has your pet traveled?
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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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Does anyone in your household smoke? *
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YesNo
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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 question, 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 known drug reactions?
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YesNo
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Do you have a UVB light for your pet?
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YesNo
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If yes to previous question, what type?
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Do you have a thermometer in the cage/area?
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YesNo
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If yes to previous question, what are the readings?
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Do you have a humidity monitor in the cage/area?
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YesNo
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If yes to previous question, what are the readings?
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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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Do you trim your pet's nails at home? *
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YesNo
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If no to the previous questions, would you like to learn?
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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 NoiseLitterbox 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 trialsNone of the Above
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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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