Your Pet's Name:
Your First Name:
Your Last Name:
Phone:
Email:
How should we contact you? Phone Email
Type of Pet:
Where did you get your pet?
How long have you owned your pet?
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 much time does your pet spend outside?
Which wildlife is in your area? (Choose all that apply) *
rabbits squirrels skunks raccoons deer none
How often is your pet around other animals that are not your own? (which species)
Do you travel with your pet? If so, where has your pet traveled?
Does your pet go to: (Choose all that apply) *
Groomer Boarding Pet Shows Pet Stores None of the Above
Does anyone in your household smoke? *
Yes No
Is your pet on pet insurance
Yes No
Is Your pet Spayed or Neutered?
Yes No
If you chose NO for the previous question, do you plan to have it done?
Yes No
Do you plan to breed your pet?
Yes No
Does your pet have any known drug reactions?
Yes No
Do you have a UVB light for your pet?
Yes No
If yes to previous question, what type?
Do you have a thermometer in the cage/area?
Yes No
If yes to previous question, what are the readings?
Do you have a humidity monitor in the cage/area?
Yes No
If yes to previous question, what are the readings?
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
Do you trim your pet's nails at home? *
Yes No
If no to the previous questions, would you like to learn?
Yes No
Check any of the following that are of concern to you regarding your pet's behavior/health(Check all that apply)
Excessive Noise Litterbox 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 None of the Above
In an emergency where you can not be immediately contacted, you want Companions Animal Hospital to: *
Provide CPR Do not resuscitate
