Client Patient Registration

Patient Registration

Please Select:

First Name & Middle Initial:

Last Name:

Please Select:

Co-Owner First Name & Middle Initial:

Last Name:

Address:

City:

State:

Zip Code:

Phone (home):

Phone (cell):

Fax:

Email:

Who referred you to us?

If not your regular veterinarian, please list your regular veterinarian and clinic:

Your Employer:

Phone:

Your Spouse's Employer:

Phone:

Driver's License/State:

Is your pet a:

Dog

Cat

Other

If other, please explain:

Pet's Name:

Breed:

Color:

Sex:

Date of Birth:

Age (years & months):

Last Distemper Vaccination Date:

Rabies Date:

Reason for Visit

A complete background and thorough history are essential to help obtain an accurate diagnosis of your pet's illness. Please fill out this questionnaire as completely as possible.

How long have you owned your pet?

Where was your pet obtained (e.g. breeder, humane society, private party, friend, etc.)

Has your pet traveled out of state in the past 2 years?

Are there any other pets in your household?

If yes, where?

Has your pet ever had ticks?

If yes, when?

Is your pet kept primarily outdoors or in the house?

If yes, what?

What is your pet's diet?

Is your pet ever fed table food?

How much and how often does your pet eat?

Has your pet been boarded or hospitalized recently?

Has your pet been treated for any major medical problems?

If yes, what and when?

Has any bloodwork been done within the past 12 months?

If yes, was Valley Fever tested for?

If yes, was Tick Fever test for?

Have any x-rays been taken within the past 12 months?

If your pet has been neutered/spayed what was his/her age of alteration?

If female and not spayed, when was her last heat?

If female, has she had any litters?

If yes, when?

Has there been a change in your pet's appetite?

If yes, is it increased or decreased?

Has there been a change in your pet's water consumption?

If yes, is it increased or decreased?

Is your pet urinating more frequently than normal?

Has your pet been straining to urinate?

Have you noticed your pet vomiting?

If yes, what is the frequency?

Has there been a change in your pet's bowel movements?

If yes, describe the appearance (color and consistency)

What is the frequency of defecation?

Has there been any straining to defecate?

Have you seen blood in any urine, vomitus, or stool?

Has your pet been scratching?

Has your pet had any seizures or convulsions?

Has there been a change in your pet's attitude or behavior?

If yes, describe:

Has there been any change in your pet's walking?

Has your pet lost any stamina lately?

Have you noticed any abnormal swellings?

If yes, where?

Have you noticed any abnormal discharges or drainage?

If yes, describe (eyes, nose, vulva; appearance):

Has your pet had difficulty breathing?

Has your pet had any coughing?

The frequency of coughing is:

It occurs most often at:

Would you describe the cough as:

Has your pet had any unexpected reactions to medications?

Has your pet received aspirin during the past 6 months?

Is your pet currently receiving medications?

If yes, give name and dosage (if known)

Please check any of the following items that your pet may have:

If other, explain:

To my knowledge my pet has no implants or metallic devices in his/her body. Please initial:

Describe your primary concern(s) about your pet:

When did this problem begin?

Additional Comments:

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