Owner First Name *
Owner Surname *
Owner Phone Number *
Dog's Name *
Breed *
Age *
Gender * Male Female
Are they desexed? * Yes No
Are they insured? * Yes No
If yes, please provide the name of insurer and policy number:
Please provide their microchip number (if you have it):
Who is/are their previous vet(s)? *
Do we have permission to contact their previous vet(s) for their history? Yes No
Where were they acquired (breeder, pet shop, rescue organisation etc.) and how long ago? *
Please list any other pets at home:
Are they up to date with their C7 vaccine? * Yes No Unsure
What parasite prevention is used for fleas/ticks, intestinal worms and heartworm? How often is it applied/administered? When was it last applied/administered? *
Describe their diet: list all foods offered, including the amount. *
What treats do they receive? Include the amount and frequency of each. *
Do they have any allergies to food or medications? If so, please list. *
Describe the problem, including when it started? *
Was there a recent change in environment before the problem started? *
Is this the first time your dog has experienced this problem? If it is recurring, please describe the frequency: *
Have you noticed any vomiting/regurgitation or diarrhoea? If so, describe the frequency, and when it was first noticed. *
Have you noticed any coughing or sneezing recently? If so, describe the frequency, and when it was first noticed. *
Are your dog's activity levels normal, or has there been a change in behaviour? If not, please describe: *
Has there been a recent change in thirst or appetite? If so, please describe. *
Please list any known health issues, medical problems, or long-term medications. *
Do you have any questions for the vet which haven't been mentioned in the above history questions?
