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: To schedule an appointment, please call into the clinic to discuss availability.