Owner's Name
*
First Name
Last Name
Email
*
example@example.com
Patient's name
*
Canine/feline:
breed:
color:
Sex:
How long have you owned your pet?
Where is your pet housed?
Please Select
Strictly Indoor
Strictly Outdoor
Both indoor/outdoor
where is your pet housed?
What is the purpose of the animal?
Please Select
Companion
Breeding
Working animal
Service animal
Other
Purpose of the animal?
For intact females: when was her last heat cycle?
Approximate is fine
For Neutered/spayed pets: when was the surgery performed?
Approximate is fine
What is your pet's current diet?
Please use brand names.
Does your pet have contact with other animals? Please explain
Has your pet ever traveled outside of Southeastern Michigan?
Yes
No
If yes please list all places your pet has been outside of southeastern Michigan
Please list the places your pet has been outside of southeastern Michigan.
What medications or daily supplements is your pet currently taking? Please provide a complete list including dosage (mg/ tablet, mg/ml) and amount you give, and include heartworm and flea and tick preventatives.
Please list the medications/treatments
What medications or treatments is your pet currently receiving, including heartworm and flea preventative?:
Please list the medications/treatments.
Has your pet had any adverse reactions to any medications?
Yes
No
If yes, which medications?
What is your main concern for your pet’s upcoming consultation? Please explain in detail.
Has your pet seen any other veterinary offices for this problem, other than your family veterinarian? (Emergency services, Holistic vet, etc..) Please provide a complete list.
Do we have permission to request medical records from the above-mentioned veterinary clinics to complete your pet’s medical record?
Yes
No
Has your pet had any illnesses, injuries or surgeries prior to this problem?
Does your pet have any history of anxiety or behavioral issues related to veterinary visits?
Is your pet currently coughing or sneezing?
Has there been any recent changes in your pet's willingness to play or exercise?
Has there been a recent change in your pet's appetite?
Has your pet recently been having any vomiting or diarrhea? Please explain
Has your pet lost or gained weight recently?
Has there been any recent change in your pet's bowel movements?
Has there been any recent change in your pet's urinary habits?
Yes
No
If yes, more or less?
Any additional comments?
Submit
Should be Empty: