New Pet History Form – Dogs, Cat

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

 
 
 


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