Patient Registration & History – Exam for Problem

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Section 1: Patient Registration

Pet's Name(Required)

Phone Number(Required)

Pet’s Breed(Required)

Pet’s Color and Markings(Required)

Pet’s Approximate Date of Birth

When did you acquire your pet?:(Required)

How did you acquire your pet (ex. From a breeder, rescue group, etc.)?:(Required)

We need to review your pet’s medical records prior to the appointment. Records from the previous veterinarian should include vaccinations, diagnoses, and treatments. Please indicate where your pet has been treated so that we may call for records in advance:

Section 2: Patient History

What problem is your pet experiencing?:(Required)

When did the problem start?:(Required)

What have you tried at home to treat the problem? (Ex. Change in diet, OTC medication, etc.):(Required)

What does your pet eat? Please include the brand name, flavor, amount fed, and feeding schedule. If you cook for your pet, please list the ingredients:(Required)

What medication is your pet taking? Please tell us the name, strength, dose, and frequency:(Required)

Is there any important medical history we need to be aware of such as previous surgery, illness, or ongoing health condition?:(Required)

Thank you for taking the time to complete this patient history form prior to your pet’s exam. This will allow us to spend quality time together during the appointment.

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