CLIENT INFORMATION:

Name: Select Ms. Mrs. Mr. Dr.    

Address:

City: State: Zip: County:

Home Phone: Work Phone:

Cellular Phone:

E-mail Address:

Are you currently experiencing a financial hardship?  Choose Yes No Explain:

PATIENT INFORMATION:

Pet’s Name: Species: Choose Feline Canine Other  

Pet Type: Choose Animal Control Breeding Animal Family Pet Feral Foster Humane Society Rescue Show Working Animal  

Primary Dog Breed: Choose Mixed Breed Unknown Affenpinscher Afghan Hound Airedale Terrier Akita Alaskan Malamute American Bulldog American Eskimo American Foxhound American Pit Bull Terrier American Staffordshire Terrier American Water Spaniel Anatolian Karabash Dog Australian Cattle Dog Australian Kelpie Australian Shepherd Australian Terrier Basenji Basset Hound Beagle Bearded Collie Beauceron Bedlington Terrier Belgian Malinois Belgian Sheepdog Belgian Tervuren Bernese Mountain Dog Bichon Frise Black and Tan Coonhound Black Russian Terrier Bloodhound Blue Heeler Bluetick Coonhound Border Collie Border Terrier Borzoi Boston Terrier Bouvier des Flandres Boxer Boykin Spaniel Briard Brittany Brussels Griffon Bull Terrier Bullmastiff Cairn Terrier Canaan Cane Corso Mastiff Cardigan Welsh Corgi Catahoula Leopard Dog Cavalier King Charles Spaniel Chesapeake Bay Retriever Chihuahua Chinese Crested Chinook Chow Chow Clumber Spaniel Cockapoo Cocker Spaniel Collie Coon Hound Curly-Coated Retriever Dachshund Dalmatian Dandie Dinmont Terrier Doberman Pinscher Dogo Argentino Dogue de Bordeaux Dutch Shepherd English Bulldog English Cocker Spaniel English Foxhound English Mastiff English Pointer English Setter English Shephard English Springer Spaniel English Toy Spaniel Field Spaniel Finnish Lapphund Finnish Spitz Flat-Coated Retriever Fox Terrier French Bulldog German Pinscher German Shepherd German Shorthaired Pointer German Spitz German Wirehaired Pointer Glen of Imaal Terrier Golden Retriever Gordon Setter Great Dane Great Pyrenees Greater Swiss Mountain Dog Greyhound Harrier Havanese Hound Hovawart Husky Ibizan Hound Irish Setter Irish Terrier Irish Water Spaniel Irish Wolfhound Italian Greyhound Jack Russell Terrier Japanese Chin Kai Dog Karelian Bear Dog Keeshond Kerry Blue Terrier Komondor Korean Jindo Kuvasz Labrador Retriever Lakeland Terrier Lancashire Heeler Lhasa Apso Lowchen Maltese Manchester Terrier Mastiff Miniature Bull Terrier Miniature Pinscher Neopolitan Mastiff New Guinea Singing Dog Newfoundland Norfolk Terrier Norwegian Buhund Norwegian Elkhound Norwegian Lundehund Norwich Terrier Old English Sheepdog Otterhound Papillon Parson Russell Terrier Pekingese Pembroke Welsh Corgi Peruvian Inca Orchid Petit Basset Griffon Vendeen Pharaoh Hound Pit Bull Plott Hound Podengo Pointer Polish Lowland Sheepdog Pomeranian Poodle, Miniature Poodle, Standard Poodle, Toy Portuguese Water Dog Pug Puli Pumi Rat Terrier Red Heeler Redbone Coonhound Retriever Rhodesian Ridgeback Rottweiler Saarlooswolfhond Saluki Samoyed Schipperke Schnauzer, Giant Schnauzer, Miniature Schnauzer, Standard Scottish Deerhound Scottish Terrier Shar-pei Sheltie Shetland Sheepdog Shiba Inu Shih Tzu Siberian Husky Silky Terrier Skye Terrier Sloughi Smooth Fox Terrier Soft-Coated Wheaten Terrier Spaniel Spinone Italiano Springer Spaniel St. Bernard Staffordshire Bull Terrier Sussex Spaniel Swedish Vallhund Terrier Thai Ridgeback Tibetan Mastiff Tibetan Spaniel Tibetan Terrier Tosa Inu Toy Fox Terrier Toy Terrier Treeing Walker Coon Hound Vizsla Weimaraner Welsh Springer Spaniel Welsh Terrier West Highland White Terrier Whippet Wire-haired Fox Terrier Wirehaired Pointing Griffon Xoloitzcuintli/Mexican Hairless Yorkshire Terrier Markings: Choose BiColor Brindle Merle Patches Solid Spots Tricolor

Primary Cat Breed Mixed Breed Other Unknown Abyssinian American Bobtail American Curl American Shorthair American Wirehair Balinese Bengal Birman Bombay Brazilian Shorthair British Shorthair Burmese Calico Chanilly / Tiffany Chartreux Colorpoint Shorthair Cornish Rex Devon Rex Domestic Long Hair Domestic Medium Hair Domestic Short Hair Egyptian Mau European Shorthair Exotic Shorthair German Rex Havana Brown Himalayan Japanese Bobtail Javanese Korat LaPerm Maine Coon Cat Manx Munchkin Norwegian Forest Cat Ocicat Oriental Persian Pixiebob Polydactyl Ragamuffin Ragdoll Russian Blue Scottish Fold Selkirk Rex Siamese Siberian Singapura Snowshoe Somali Sphynx Tonkinese Turkish Angora Turkish Van Choose Markings: Choose Bicolor Calico Solid Spotted Tabby Tortie Tricolor Tuxedo

Primary Color Choose Black White Brown Tan Gray Mixed Red Yellow Orange Buff Green Other   

2nd Color:       Choose Black Brown Gray Orange Tan White Yellow    Birth Date (aprox): 00/00/0000:

Sex: Choose One Spayed Female Female Neutered Male Male Unknown

Do you wish to drop off your pet at 7:30 a.m.? CHOOSE YES NO

Referring Animal Hospital/Clinic:

Has Your Pet Had it's Rabies Vaccination in the Last Year: Yes No

Medical History:

Please describe:

•  Any Medical Alerts?:      

• Any Medical Conditions?

• Any Patient Alerts:          Choose Careful Use Caution Feral

• Seizures?                        Choose Yes No

• Where Does Your Pet Sleep? Choose Indoor Only Indoor-Outdoor Outdoor Only

• Is Your Pet on a Special Diet? Choose Yes No

Has your pet been to a vet within the past 12 months? CHOOSE Yes No

Is your pet under veterinarian care now? CHOOSE Yes No

How long have you had the pet? 

Has your pet had any reaction to medications? CHOOSE Yes No

Is your pet on medications currently? CHOOSE Yes No

If so, What kind?

Is your pet injured? CHOOSE Yes No   Date of Injury:

Current Pet Condition

What are your goals for this appointment: