Your Pet's Name:
Your First Name:
Your Last Name:
Phone:
Email:
How should we contact you? Phone Email
Type of Pet: Dog Cat
Where did you get your pet?
How long have you owned your pet?
What prior illness or health issues has your pet had?
How often do you bathe your pet?
How often do you brush/comb your pet?
What type of exercise does your pet receive, and how often?
How often is your pet around other animals (other than your own)?
How much time does your pet spend outside?
Which wildlife is in your area? (Choose all that apply) *
rabbits squirrels skunks raccoons deer none
Does your pet go to: (Choose all that apply) *
Groomer Boarding Pet Shows Pet Stores None of the Above
Do you travel with your pet? If so, where else has your pet been?
Is your pet on pet insurance
Yes No
Is Your pet Spayed or Neutered? *
Yes No
If you chose NO for the previous questions, do you plan to have it done?
Yes No
Do you plan to breed your pet? *
Yes No
Does your pet have any drug or vaccine reactions? *
Yes No
Does your pet hunt?*
Yes No
Is your pet on a preventative for controlling external parasites? (fleas and ticks) *
Yes No
Is your pet on a preventative for controlling internal parasites? (heartworm, roundworm, etc) *
Yes No
Has your pet been micro-chipped or tattooed? *
Yes No
Has your pet ever had professional dental care? *
Yes No
Do you understand the health benefits and life extending effects of providing proper dental care for *
Yes No
Do you trim your pet's nails at home? *
Yes No
Would you like to learn how to trim your pet's nails? *
Yes No
Check any of the following that are of concern to you regarding your pet's behavior/health *(Check all that apply )
Excessive Barking House Training Soiling/Spraying inside Problems around children Shedding Anxiety Jumping Straying from home Itching/scratching Overly rambunctious Biting Clawing or digging Bad breath Destructive Behavior None of the Above
Which of the following are services that you might utilize: *(Check all that apply )
Lodging/boarding facility Referral rewards program Wellness plans Massage therapy Evening hours Grooming Day care Product trials
In an emergency where you can not be immediately contacted, you want Companions Animal Hospital to: *
Provide CPR Do not resuscitate
