"*" indicates required fields

Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care.

Has any of your information changed?*

Yes

This includes home address, phone number, email address, co-owner, etc

Information to be Changed

Co-Owner Name

Phone

Address

Street Address

Address Line 2

City

State

ZIP Code

Client Information

Name*

First

Last

Email*

Appointment Date*

MM slash DD slash YYYY

Appointment Time*

Hours

Minutes

AM/PM

During carside appointments, it is imperitive that we be able to reach you in a timely manner while your pet is in the building. Please have your cell phone listed below available and be free to talk. If you need to leave your car, leave the parking lot or will be otherwise occupied while your pet is here, please ask us about a drop off appointment.

What phone number can we call you at while your pet is here?*

Pet Information

Pet's Name*

Pet's Age*

Species*

Cat

Dog

Breed*

Microchipping is permanent identification for your pet. Having your pet microchipped is an excellent way to locate your pet should it become lost.*

My pet is already microchipped

I’m interested in learning more

I’m not interested in microchipping

Are there any concerns for the nurse to consider this visit?*

Good appetite?*

Drinking and urinating normally?*

Any sneezing? Coughing? Itching?*

Vomiting or Diarrhea?*

Any aggression, housebreaking issues, or changes in normal routines?*

Please describe your pet's outdoor activities*

We recommend annual fecal testing or intestinal parasites (Intestinal Parasite Exam).*

Bringing small sample to appointment

Please send home a prepaid collection container to drop off sample at my convenience

I would like to to learn more about regular fecal testing

Other

If Other, please explain*

My pet eats: (choose all that apply)*

Wet Food Only

Dry Food Only

Wet and Dry Mixture

People Food

Raw Diet

Home Cooked Diet

Other

If Other, please explain*

Brand of pet food*

If prescription diet, what formulation?*

How often is your pet fed?*

How much is your pet fed?*

In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides, etc)*

Do you brush your pet's teeth? How often?*

Current medications / supplements (name, dose, frequency given)*

Any refills needed?

To help keep healthy, year round heartworm prevention is needed due to the variable nature of mosquito seasons. Mosquitoes can be known to live in your basement/attic and in the sewer system all winter. In addition, heartworm preventatives once monthly help prevent several intestinal parasite infections. We recommend Interceptor Plus once monthly on a year round basis.

Heartworm Prevention refill?*

I want to discuss Heartworm Disease Prevention options with a vet nurse

I have prevention at home

My pet does need to be protected against Heartworm Disease

Other

If Other, please explain*

Flea Prevention refill?*

I want to discuss flea prevention options with a vet nurse

I have prevention at home

My pet does need to be protected against fleas

Other

If Other, please explain*

Is there anything else you would like to discuss today?

Any history of vaccine or medication reactions?

Yes

Do you know which vaccine or medication?

Companion Animal Hospital is committed to the safety of my pet(s). I understand that my pet needs to be on a leash or in a carrier upon arrival to the hospital.*

Please Initial

I understand that payment is due, in full, at the time services are rendered. This includes services authorized by my proxy; by another responsible party listed on my account; and/or by phone.*

Please Initial

Signature*

This field is for validation purposes and should be left unchanged.

Nurse Appointment Form

Information to be Changed

Client Information

Pet Information

What's Next

Call us or schedule an appointment online.

Meet with a doctor for an initial exam.

Put a plan together for your pet.

Where family pets find loving care