Cat & Dog Medical History

Owner's Full Name *

Co-Owner's Full Name

Phone Number *

Secondary Phone Number

Address *

City *

Province *

Postal Code *

Email *

Pet's Name *

Pet Species / Breed *

Your Pet's Age (and D.O.B if known) *

Pet's Gender

Consent to take pictures for social media *

Yes
No

Send claim to insurance?*

Yes
No

What is the primary reason for your visit?

Describe in more detail the symptoms marked

How long has your pet had these symptoms?

Any other pets in your home affected? If yes, please elaborate

My pet spends time

Inside
Outside
Both

All vaccines up to date?

Yes
No
Unsure

Has your pet been on any medications or supplements recently? If yes, please provide the name and frequency of doses:

What food and treats do you feed your pet?

Have you travelled with your pet recently? If yes, where?

Any additional comments or questions

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

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