Client Questionnaire

Primary Owner (required)

Primary Owner Email (required)

Primary Owner Phone (required)

Secondary Owner

Relationship to Owner
SpouseFriendFamily MemberCo-worker

Secondary Owner Email

Secondary Owner Phone

Owner Address:
Street

City

Province

Postal Code

Medical History

Is there a previous animal hospital we can contact for your pet’s previous medical history?

Hospital Name

Hospital Email

Hospital Phone

Pet Information
Pets Name* (required)

Breed* (required)

Color

Pet Date of birth:

Sex
MaleFemale

Spayed/Neutered?
YesNo
Does your pet have a microchip?
YesNo

Microchip Number

Does your pet have health insurance?
YesNo

Name of insurance company

Policy Number

Can we take your pets photo?

This would be added to their account & potentially social media.

YesNo
Your Pet's social media account

Current Medications/Supplements

Please list all medications, supplements, and preventatives your pet is currently taking. Or N/A if they are not on any.

Would you like to discuss any medications, supplements and/or preventatives with the veterinarian?
YesNo

Have you noticed any of the following?

Please select all that are present in your pet.

CoughingVomitingLamenessSneezingDiarrheaPainBehavioral ChangesNew LumpsDifficulty standing/jumping/playingPresence of fleas, ticks, or tapewormsChanges in appetiteDecreased grooming/change in grooming patternsN/A

Has your pet traveled recently or does he/she travel with you routinely
YesNo

Diet

Please list the specific name(s) of the food that you are feeding (include both dry and wet food). How much do you feed your pet, and how many times a day?

Are these specifically measured amounts?
YesNo

Does your pet receive treats/human food?
YesNo

Would you like to discuss your pet’s nutrition with the veterinarian?
YesNo

Other Questions

Would you like more information on any of the follow (please check all that apply)

Pet health insuranceLyme diseaseFlea and tick preventionHeartworm diseaseInternal parasitesVaccinesTraining Behavior

Rate your pet’s water consumption
Too muchThe right amountNot enough

Has this changed recently?
YesNo
How/who did you hear about us?
Walked/Drove by/SignageInternet searchSocial MediaWord of mouthFriend or Family
Name of referral: