The following information is necessary so that we might serve you better and give you more personal attention, as well as to minimize mis-communications between you and this hospital. Please fill out the form completely. Filling out this form is in the best interest of your pet’s health during its hospitalization or during the pre-operative, surgical and post-operative periods ahead. Thank you!

Today’s Date

Time of Admission

Owner *

Address

Address

City/Town

ZIP/Postal Code

Telephone (Day)

Telephone (Evening)

Telephone (Emergency)

Email *

Pet’s Name

Breed

Age

Sex

Is there a fax # where we could send you an estimate, if needed?

External Medicine

Is your pet itching itself?

Yes

Where?

And how long?

On a scale of 1 to 10, how bad is the itching?

Have you noticed any recent or chronic eyes, ears, nose, throat, teeth or skin problems?

Yes

Explain

For how long?

Does your pet swim or get bathed often?

Yes

How often?

Explain

Medications

Is your pet on any medication?

Yes

Please list all veterinary or human medications given in the past 14 days

Why is your pet on these medications?

Is your pet on any oral supplements?

Yes

What type?

Do you use any type of flea control for your pet?

Yes

Which Ones?

Does your pet have any known allergies to drugs or vaccinations?

Yes

What medications?

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Pet Medical History Form

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