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Home
Our Hospital
Our Doctors
Hospital Tour
Forms
Careers
Veterinarian Careers
Hospital Support Careers
Emergency Information
Covid-19 Information
Anesthesia and Your Pet
Ticks! Now What?
Services
Wellness Exams
Spay & Neuter
Vaccinations
Microchipping
Dental Care
Laser Therapy
View All Services
Payment Options
Shop Online
Contact Us
517-223-8812
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Canine and Feline History Form
Canine and Feline History Form
"
*
" indicates required fields
Client Information
Owner Name
*
Owner Phone
*
Patient Information
Pet's Name
*
Species
*
Age
*
Color
*
Gender
*
Male
Female
Unknown
Spayed or neutered status
*
Neutered
Spayed
Intact
Reason for Visit
*
Current Diet (amount, frequency), including treats
*
Any Changes in Drinking
*
Please select all the locations your pet goes to
*
Groomer
Boarding
Kennel
Daycare
Classes
None
Where does your pet go to be groomed
*
Where does your pet go to be boarded
*
Where does your pet go to be kenneled
*
Where does your pet go for daycare
*
Where does your pet go for classes
*
Is your pet on Heartworm Prevention?
*
Yes
No
When was the last dose of Heartworm Prevention given and what brand
*
Do you give Heartworm Prevention year-round or seasonally
*
Year-Round
Seasonally
Is your pet on Flea and Tick Prevention
*
Yes
No
When was the last dose of Flea and Tick Prevention given and what brand
*
Do you give Flea and Tick Prevention year-round or seasonally
*
Year-Round
Seasonally
Is your pet on any Current Medications or Supplements
*
Yes
No
Please list the Current Medications or Supplements your pet is on
*
Has your pet received any previous vaccines
*
Yes
No
Please list any previous vaccines your pet has received
*
Has your pet had any previous vaccine reactions
*
Yes
No
Please explain any previous vaccine reactions your pet has had
*
Are there any other issues or concerns you'd like to discuss with the doctor?
*
Consent to Additional Costs:
*
After reviewing my initial estimate, I acknowledge and understand that certain services, such as Bloodwork, Vaccines, Medication/Sedation meds, E-Collar, Laser treatments, Microchipping, and CPR/DNR may have additional costs.
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