Canine Medical History

Contact Info

Name

First

Last

Phone Number

Dog's Name

Breed

Color

Pet's Date of Birth/Age

Sex

Primary Reason for Today's Visit

What brings you in to our hospital?

Do you have any concerns about your pet's health?

Please elaborate: Have you tried anything to treat these problems so far?

Tell me about your pet's lifestyle:

Describe their diet:

Describe what medications and supplements your pet is taking:

Which heartworm preventative do you give your pet?

Which flea/tick preventative do you give your pet?

How many months a year does your pet receive heartworm and flea/tick medication?

Please enter a number from 1 to 12.

Do you need refills on heartworm or flea/tick preventatives or any other medications?

Does your pet have a microchip?