Associated Veterinary Specialists - Advanced Veterinary Care - St. Louis, MO
Specialized St. Louis Veterinary Services AVS Veterinary News
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?