Welcome

Thank you for giving us the opportunity to care for your pet. We'll be happy to answer any questions you have about your pet's health. To ensure the best possible, please take the time to fill in this form completely. Thank you!

REGISTRATION

Owner's Name       Significant Other
Children (first names and ages)
Address
City Zip Code
Home Phone Cell Phone
Email Fax
Employer's Name and Address 
Position Work number
Spouse/Other's Employer and Address
Position Work number
 

At what time  and at what phone number
is it best to call you about your pet.
In case of EMERGENCY, please call at phone

We will gladly prepare a written estimate for your pet's care. Please ask the receptionist before leaving.
PROFESSIONAL FEES ARE DUE AND PAYABLE AT THE TIME SERVICES ARE RENDERED. IT IS CUSTOMARY TO LEAVE A DEPOSIT OF 50% ON HOSPITALIZED PATIENTS.

I will be paying by Pet Insurance Check
Credit Card Cash
SSN   Driver License # Expires  

How did you hear about our Hospital?

Individual, who we may thank. Referred By
Website
Hospital sign/Drive by
Yellow Pages
Mail
Ad/Flyer

We consider our pet(s) Part of the family Like a child Breeding Animal
Just a pet Working animal

I want the best possible care for my pet - finances are not the primary concern
Do whatever my pet requires
I prefer knowing about less expensive options in caring for my pet 
Advise me of all costs
Although I like my pet, finances are a major concern
I want to learn as much as possible about the care of my pet, please educate me in detail
I am not interested in a lot of information. Just tell me what the bottom line is
I appreciate written information
I don't enjoy reading
I want to be present for my pet's procedure
I don't like watching medical procedures

Comments
 

To prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must be current on all vaccines and free of internal and external parasites. I authorize the doctor to provide vaccines and parasite control as needed for my pet.

Signature ________________________________  Date ________________

 

PET HEALTH HISTORY

Pet name Species
Breed Age
Description/color Sex
Spayed/Neutered
Vaccination dates
Dog DHPP       Parvo    Corona
Bordetella  Rabies
Cat FVRCPC   FELV   FIP      
Rabies     
Preventative care dates
Fecal Exam  Deworming  FELV Test       
EKG            Dentistry    X-Rays               
Urinalysis    Heartworm Test 
Heartworm Preventative   Complete Blood Test
Length of time pet owned      
Pet origin Humane Society Pet Shop
Breeder  Friend
Stray Other
Prior Illness Date
Prior Surgery Date
Allergies

Pet's lifestyle Mostly indoors, supervised when outside  Strictly indoors
Free to roam In the backyard
Pet's diet Pet store food Dry   Canned
Supermarket food Dry   Canned
Diet varied  Always same food Table foods
Fed   times a day Free choice

Travel History Always in So California Travels in state
Travel outside state (name state) 
  Camping

Grooming How often Products Used
Dental Care How often Products Used
Ear Care  How often Products Used

Have you noticed any changes in

Weight   Water Consumption  
Urination habits   Stools  
Behavior   Energy Level  
Exercise   Vision/Eyes  
Skin/Haircoat      

Has there been any

Vomiting   Straining to urinate/defecate  
Blood in stool/urine   Seizuring  
Weakness   Limping/Stiffness  
Unusual Odors      

Comments

Clicking the Submit button will submit the information to us and enable you to print out a copy of the filled-in form.