You may download this form in PDF format and bring it with you, or you may e-mail the form by clicking on the red box at the end of the form. Have you been to this office with any other pet? YES NO Mr. Mrs. Ms. Dr. Last Name: First Name: Spouse/Other: Address: City: State: Zip Code: Home Phone: Business Phone: Cell/Pager Number: Email: Place of Employment: Referring Veterinarian's Name: Referring Veterinary Hospital: Spouse's Place of Employment: Spouse's Business Phone: Driver's License Number: (For ID Purposes) Pet Name: Dog Cat Breed: Sex: Male Male-Neutered Female Female-Spayed Date of Birth: Allergies: Color: Please give approximate dates of the following routine medical care: DOGS HeartwormTest: Heartworm Preventative: Yes No Distemper Vaccine: Rabies Vaccine: CATS Feline Leukemia/FIV: Leukemia Vaccine: Distemper Vaccine: Rabies Vaccine: • Do you have pet health insurance? YES NO • Where did you obtain your pet? • How long have you owned your pet? • Where is your pet housed? Indoors Outdoors Both Other • Intended purpose of your pet? Pet Show Sport Guard Other • For intact females, when, approximately was your pet’s last heat cycle? • For neutered/spayed pets, when, approximately, was the surgery performed? • What is your pet’s current diet? (include brand) • Does your pet have any food allergies? YES NO • Has your pet had any bad reactions to a medication? YES NO • Does your pet have contact with other animals? YES NO • Is your pet microchipped? YES NO • Has your pet ever been out of the St. Louis Metro Area? YES NO If yes, please indicate where below: • Is your pet currently receiving any medications? YES NO Please list medication Below • Has your pet had any illness, injury, or surgery prior to the current problem? Explain Below YES NO •Is your pet currently coughing or sneezing? YES NO • Has there been a recent change in your pet’s appetite? YES NO • Has your pet lost or gained weight recently? YES NO • Is your pet currently vomiting? YES NO • Has there been any recent change in your pet’s bowel movement? YES NO • Have there been any recent changes in your pet’s urinary habits? YES NO • Have you noticed a change in the amount of water your pet drinks? YES NO • What is the date of your pet’s appointment?