Canine Wellness Visit – New Client Form

Name: One Love Animal Hospital
Address: 317 Atlantic Ave, Brooklyn, NY, 11201, USA
Telephone: (718) 532-7410

Canine Wellness Visit Questionaire For New Clients

Email Us Here: Boerum Hill: [email protected] | Bay Ridge: [email protected] | Yorkville: [email protected]

Download PDF Version here

Practice / Location

Date

Your Name *

Your Phone

Your Email *

Pet Name *

Sex and Reproductive Status (Select One)

Male Intact

Male Neutered

Female Intact

Female Spayed

Age

Microchip #:

History

Current Medications

Please indicate if any medication was prescribed by another clinician since your last visit. Use reverse side if necessary

Name of Medication

Dose (mg/day, ml/day, tablets/day)

Date started/purpose

Name of Medication

Dose (mg/day, ml/day, tablets/day)

Date started/purpose

Name of Medication

Dose (mg/day, ml/day, tablets/day)

Date started/purpose

Name of Medication

Dose (mg/day, ml/day, tablets/day)

Date started/purpose

Do you give heartworm and flea/tick preventative?

None

Yes

Brand(s)

Date last given?

Have you ever seen any fleas or ticks on your pet?

Yes

When?

What treatment was administered?

Do you give your pet any supplements/vitamins?

Other Information:

Please list any further information or questions concerning your pet’s health.

I certify that the above information is correct to the best of my knowledge and that I have not purposefully misrepresented my pet’s health history. I will furnish One Love Animal Hospital with a copy of my pet’s prior medical records at the time of my appointment. I will not hold any member of One Love Animal Hospital responsible for errors or omissions that I may have made in completing this form. *

Owner’s Signature

Sign above

Date