Patient Registration & History Form | Companion Pet Hospital

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Section 1: Patient Registration

Pet's Name*

Phone Number*

Pet Information

Species*

Breed*

Color and Markings*

Gender*

Approximate Date of Birth

Does your pet have a microchip?*

Does your pet have insurance?*

When did you acquire your pet?*

How did you acquire your pet (breeder, rescue group, etc.)?*

We plan to offer food treats to make your pet’s visit more enjoyable. Are there restrictions we need to know about? Please feel free to bring your pet’s favorite treats from home!*

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: Lifestyle

The following questions help us learn more about your pet so that we can tailor our preventative care recommendations to their unique lifestyle.

What does your pet eat? Please state brand/flavor of food, amount fed, and feeding schedule. (Ex. Purina Proplan Large Breed, 2 cups, twice a day.) If you cook for your pet, please list ingredients:*

How much time does your pet spend outdoors?*

Does your pet travel outside of the Hudson Valley?*

What kind of contact does your pet have with other animals?*

Does your pet go to a groomer, day-care, or boarding facility with specific vaccine requirements (Ex. Canine Influenza)?*

Section 3: Medications

It is important for us to know what medications your pet takes regularly or intermittently. This information reduces the risk of adverse drug interactions and helps us make healthy recommendations for your pet.

Are you interested in a single injection of heartworm preventative that lasts all year?*

Do you need a prescription refill during today’s visit?*

What other medications does your pet take? Please indicate name, strength, dose, and frequency. (Ex. Thyro-tabs 0.6mg, 1 pill, every 12 hours.):*

If none, please type 'N/A' into field.

Section 4: Health Concerns

When you see your pet every day you may not notice small changes in their behaviors. The purpose of this section is to identify any signs that may be significant to your pet’s health. Early diagnosis and treatment will maintain your pet’s quality of life.

What other concerns do you wish to discuss with the vet today?:*

Section 5: Medical History

Has your pet ever had an adverse or allergic reaction to a vaccine?*

If you answered 'yes' to the above question, please describe reaction:*

Do you wish to update all due vaccinations if the vet feels it is safe to do so?*

Is there any important history we need to be aware of such as previous surgery, illness, or ongoing health condition?*

If none, please type 'N/A' into field.

Section 6: Diagnostic Testing and Health Screening

All pets should be screened annually for early signs of disease even if they seem healthy. Recommended testing may include: CBC (complete blood cell count), Chemistry (evaluation of organ function), Thyroid level, and Urinalysis. At minimum, pets need to be checked for parasites and infectious diseases that could be contagious.

Do you wish to pursue full preventative care screening tests today?*

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Patient Registration & History Form: Wellness/Preventative Care Exam