Whitney Veterinary Hospital New Client Form

Your Pet's Medical History (Please complete for each pet)


	Pet #1	Pet #2	Pet #3
Name
Species (cat/dog)
Breed
Description (color)
Age (years)
Date of Birth
Sex
Length of time Owned
Neutered or Spayed
Diet (Kind of Pet Food)
Hours Spent Outside Each Day

Last Vaccination Dates
DHP (distemper - dog)
Parvovirus (dog)
FVRCP (distemper-cat)
Rabies (dog/cat)
Other Vaccines

Last Heartworm Test
Heartworm Prevention
Last Fecal Exam (worms-dog/cat)
Last Dental Cleaning
Prior Illness
Prior Surgery
Current Medications

Where did you get your pet? (Please circle):
shelter

Friend

Breeder

Pet Shop

Stray

Individual(nonbreeder)

Previous Veterinarian's Name:________________________________________________________
Address:_________________________________________________________________________
May We Request Your Pet's Past Medical Records?___________Yes_____________No

Reason For This Visit:______________________________________________________________
_________________________________________________________________________________

Thank you for choosing Whitney Veterinary Hospital and Cat Care Clinic.
We look forward to serving you and your pet. Our mission is to treat each pet as if it
were our own and each client with concern and compassion.
Please let us know how we are doing.