patient registration

please complete the form below

    CLIENT INFORMATION

    PET INFORMATION

    Name

    Breed

    Color

    Age

    Species
    CanineFelineOther

    Sex

    Microchip #

    VACCINATIONS

    Is your pet up to date on their vaccinations?
    If yes, please provide list of vaccines and due dates if you know them.
    NoYes

    Has your pet ever had an allergic reaction to a vaccine?
    NoYes

    ENVIRONMENT

    My pet is
    Exclusively indoorExclusively outdoorBoth indoor & outdoor

    Has your pet travelled out of California?
    If yes, where?
    NoYes

    Are there other pets in the house?
    If yes, describe
    NoYes

    FLEA | TICK | HEARTWORM | DEWORMING

    Is your pet on flea/tick preventive?
    If yes, what product & when was it last administered?
    NoYes

    Is your pet on heartworm preventive?
    If yes, what product & when was it last administered?
    NoYes

    When was your pets last heartworm test?

    WELLNESS TESTING

    When was your pets last fecal test?

    For cats, has your cat been tested for FELV (leukemia) or FIV?
    YesNoDoes not apply

    DIET

    What diet is your pet currently on?

    Does your pet have any food allergies?
    If yes, describe
    NoYes

    MEDICATIONS/SUPPLEMENTS

    Is your pet on any medications?
    If yes, please list drug name, dose, and how often it is administered
    NoYes

    Does your pet receive any supplements?
    If yes, please list drug name, dose, and how often it is administered
    NoYes

    Does your pet have any known medication allergies?
    If yes, please describe
    NoYes

    Does your pet have any previous medical conditions?
    If yes, please describe
    NoYes

    FEAR-FREE APPROACH

    We would like to do anything we can to reduce your pet's fear, anxiety and stress.

    How does your pet do at the vet?

    May we give your pet treats during their visit?
    YesNo

    Does your pet prefer you in the room during treatments?
    YesNo

    Which does your pet prefer?
    Male veterinary staff membersFemale veterinary staff membersNo preference

    Do you have any other tips/tricks to help us reduce your pets stress during their visit?