Patient Information - Canine

Patient #__________________________ (Office use)
Patient's Name___________________________________________________________

Breed____________________________________ Birthdate (approximate) _______________________

Color____________________________________Sex: Male (   ) Female (   )

Check here if your dog has been spayed or neutered? (   )

Please give the approximate age that your dog was spayed or neutered at___________________

How did you acquire this dog? (Breeder, Pet Store, Friend, Humane Society, Newspaper Ad, etc. )
___________________________________________________

What does this dog get to eat?_________________________________________________

_______________________________________________________________________________

Does he/she get table foods?___________________________________________________

Does he/she get other treats?__________________________________________________

Has this dog ever been vaccinated for the following:

Distemper	Yes (   ) No (   ) When__________________
Parvovirus	Yes (   ) No (   ) When__________________
Coronovirus	Yes (   ) No (   ) When__________________
Rabies	Yes (   ) No (   ) When__________________
Lyme	Yes (   ) No (   ) When__________________

Has your dog ever been tested for Heartworms? Yes(   ) No(   ) When__________

Is he/she currently on Heartworm preventative? Yes(   ) No(   ) What kind?__________

Has this dog ever had a stool sample checked for internal parasites? Yes (   ) No (   )

When was the last time?________________________________________

Does this individual ever compete in Dog shows, Obedience trials, Field trials, or other competition
(If so, please describe)_____________________________________________________________________


Please print out this form, fill in the information, and either bring it along with your pet, or FAX it to 913-829-1920