Client_Patient_RegistrationPlease Select– Select –Mr.Mrs.Ms.Dr.First NameMiddle InitialLast NameCo Owner First NameCo Owner Middle InitialCo Owner Last NameAddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweHome PhoneCell PhoneFaxEmailWho referred you to us?If not your regular veterinarian, please list your regular veterinarian and clinic:Your EmployerEmployer PhoneYour Spouse’s EmployerSpouse’s Employer PhoneDrivers License/StateIs your pet a:– Select –DogCatOtherIf other, please explain:Pets NameBreedColorSexDate of BirthAgeLast Distemper Vaccination DateRabies DateReason for VisitA complete background and thorough history are essential to help obtain an accurate diagnosis of your pet’s illness. Please fill out this questionnaire as completely as possible.How long have you owned your pet?Where was your pet obtained (e.g. breeder, humane society, private party, friend, etc.)Has your pet traveled out of state in the past 2 years?– Select –YesNoAre there any other pets in your household?– Select –YesNoIf yes, where?Has your pet ever had ticks?– Select –YesNoIf yes, when?Is your pet kept primarily outdoors or in the house?What is your pet’s diet?Is your pet ever fed table food?– Select –YesNoHow much and how often does your pet eat?Has your pet been boarded or hospitalized recently?Has your pet been treated for any major medical problems?– Select –YesNoUnknownIf yes, what and when?Has any bloodwork been done within the past 12 months?– Select –YesNoUnknownIf yes, was Valley Fever tested for?– Select –YesNoUnknownIf yes, was Tick Fever test for?– Select –YesNoUnknownHave any x-rays been taken within the past 12 months?– Select –YesNoUnknownIf your pet has been neutered/spayed what was his/her age of alteration?If female and not spayed, when was her last heat?If female, has she had any litters?– Select –YesNoUnknownIf yes, when?Has there been a change in your pet’s appetite?– Select –YesNoUnknownIf yes, is it increased or decreased?Has there been a change in your pet’s water consumption?– Select –YesNoUnknownIf yes, is it increased or decreased?Is your pet urinating more frequently than normal?– Select –YesNoUnknownHas your pet been straining to urinate?– Select –YesNoUnknownHave you noticed your pet vomiting?– Select –YesNoUnknownIf yes, what is the frequency?Has there been a change in your pet’s bowel movements?– Select –YesNoUnknownIf yes, describe the appearance (color and consistency)What is the frequency of defecation?Has there been any straining to defecate?– Select –YesNoUnknownHave you seen blood in any urine, vomitus, or stool?– Select –YesNoUnknownHas your pet been scratching?– Select –YesNoUnknownHas your pet had any seizures or convulsions?– Select –YesNoUnknownHas there been a change in your pet’s attitude or behavior?– Select –YesNoUnknownIf yes, describe:Has there been any change in your pet’s walking?– Select –YesNoUnknownHas your pet lost any stamina lately?– Select –YesNoUnknownHave you noticed any abnormal swellings?– Select –YesNoUnknownIf yes, where?Have you noticed any abnormal discharges or drainage?– Select –YesNoUnknownIf yes, describe (eyes, nose, vulva; appearance)Has your pet had difficulty breathing?– Select –YesNoUnknownHas your pet had any coughing?– Select –YesNoUnknownThe frequency of coughing is– Select –OccassionalFrequentContinuousIt occurs most often at– Select –NightMorningExerciseWould you describe the cough as– Select –MildModerateSevereHas your pet had any unexpected reactions to medications?– Select –YesNoUnknownHas your pet received aspirin during the past 6 months?– Select –YesNoUnknownIs your pet currently receiving medications?– Select –YesNoUnknownIf yes, give name and dosage (if known)Please check any of the following items that your pet may have Avid Chip (ID microchip inserted under the skin) Metal Dental Work (e.g. crowns) Pacemaker Orthopedic implants Birdshot Stainless Steel Suture Surgical Staples Other (please explain below)If other, explain:To my knowledge my pet has no implants or metallic devices in his/her body. Please initialDescribe your primary concern(s) about your petWhen did this problem begin?Additional Comments In order to ensure you have a backup of your submission, please print and/or email a copy of this form. To print a copy of this form: Prior to submission, click the print function from your browser. To receive a confirmation copy of this form via email: Enter your email address in the Email Address box If you do not receive the confirmation copy shortly after submission, please contact us. Your EmailSubmit Form
