Cell Phone Number * Email * Pet Name * Species (dog, catc, etc.) * Breed * Age of Pet * Why are we seeing your pet today? * If your pet is sick, when did this start? If not described above, please explain any changes in appetite or thirst: If not described above, please explain any changes in urination or bowel movements: If not described above, please explain if your pet experiencing any coughing, sneezing, vomiting or diarrhea: If not described above, please explain if your pet has any new lumps or bumps: If not described above, please explain if you pet has any mobility issues: Is your pet on any medications (including heartworm, flea and tick medication, and supplements)? * Do you need any refills today? What is your pet’s normal diet, and have there been any recent change in diet? Do you have any other concerns or requests? Does your pet have any known allergies? Do you consent to allow X-rays today if deemed necessary by the veterinarian? Do you consent to allow blood work today if deemed necessary by the veterinarian? Do you consent to updating vaccines today if the veterinarian feels this is appropriate? For Cats Does your cat go outside of the house? Do any other cats in the household go outside of your house? Are there any litter box issues in the household? If yes, please explain: For Dogs Does your dog need an updated Bordetella (Kennel Cough) vaccine for the kennel, daycare, or grooming? Please note that some boarding facilities require this vaccine every six months. For Other Species Please provide details regarding where and when you acquired your pet, your pet’s living environment at home (type of cage, bedding, heat element, etc.), feeding (diet and schedule), supplements, and any other husbandry information that is relevant to today’s visit?