Patient Name:

 

Breed:

 

  Sex:  Female   Female Spayed

           Male       Male Neutered  

 

 Color and Markings:

 

Birth Date or Age:

 

      Vaccinations Received:                     Date Given:

     Distemper/Hepatitis/Parainfluenza     

     Leptospirosis                                        

     Parvo                                                                         

     Rabies                                                                         

     Bordetella                                                                                   

     Lyme                                                                                                                      

 

  Has your dog been tested for Heartworm Disease?       Yes      No

 

  If Yes, when and where was the test performed:

 

  Heartworm Test Result:    Negative          Positive

 

Number of hours your dog spends outside each day:

 

 

Previous medical or behavior problems:

 

Present medical or behavior 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 wish to submit at this time

I will fill out information on another pet also

 

    

 

 

 

Signature of Owner: __________________________________

 

Date: _______________________________________________

(to be signed at the time of first appointment)

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