Patient Name:  

Breed: 

  Sex:  Female   Female Spayed

           Male       Male Neutered 

 

 Color and Markings:

 

Birth Date or Age:

 

  Vaccinations Received:                     Date Given    

     Distemper (FVRCP)                                                  

     Leukemia                                                                                   

     Rabies                                                                                                                                       

 Has your cat been tested for Leukemia?    Yes         No

 

 If Yes, what was the result?                Negative Positive

 

Number of hours your cat spends outside each day: 

 

Previous medical problems:

 

Present medical problems:

 

Current medications, special diets, etc:

 

Known drug allergies:

none

 

 

If you are transferring from another animal hospital please have your pet’s medical history faxed to us in advance of your appointment at (585) 388-0202

 

 

     This is the only pet I want to submit at this time

     I will submit another pet’s information

 

                                                    

 

 

 

Signature of Owner: ______________________________

 

Date: __________________________________________

(to be signed at time of first appointment)

Please fill out information for only ONE patient at a time, thanks.