Patient Information -- Canine Dog’s Name: _________________________Birthdate (approx): _______________ Breed:____________________ Color: _________________ Sex:   MALE    FEMALE Has your dog been spayed or neutered? Please circle. YES NO If so, at what age? _________________ How did you acquire this dog? (Breeder, pet store, friend, shelter, newspaper ad, etc. _______________________________________ What does this dog get to eat? (Includes kibble, canned, table food and treats.) _________________________________________________________________________________ _______________________________________________________ Has this dog ever been vaccinated for the following: Rabies YES (   )  NO (   ) Date: _____________________ Distemper YES (   )  NO (   ) Date: _____________________ Parvo YES (   )  NO (   ) Date: _____________________ Bordetella YES (   )  NO (   ) Date: _____________________ Lepto YES (   )  NO (   ) Date: _____________________ Lyme YES (   )  NO (   ) Date: _____________________ Has your dog ever been tested for heartworms? YES NO If so, when? _______________________________ Is your pet on heartworm preventative? YES NO If so, what kind?____________________________ Has this pet ever had a stool sample checked? YES NO If so, when?________________________________ Does/will this pet go to a groomer/boarding facility? YES        NO  Does/will this pet get exposed to ticks? YES        NO  (ex: camping, wooded areas, at home) Does/will this pet get exposed to wildlife? YES NO (ex: camping, wooded areas, parks, at home) Does this pet have any other medical conditions? YES NO If so, please explain: _________________________________________________________________________________ _______________________________________________________
Please print out this form, fill in the information, and either bring it along with your pet, or FAX it to 866-866-7558
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