Owner First Name *
Owner Surname *
Owner Phone Number *
Dog's Name *
Breed *
Gender * Male Female
Are they desexed? * Yes No
Age *
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):
Have they been to another vet? * Yes No Unsure
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:
What vaccines have they had so far, and when? *
What parasite prevention is used for fleas/ticks, intestinal worms and heartworm? How often is it applied/administered? When was it last applied/administered? *
Do you need advice and/or recommendations about parasite prevention during your consultation? *
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. *
Are they enrolled in puppy preschool? If not, would you like more information about our puppy preschool classes? *
Do you require any advice about socialisation for your puppy? *
Do you require any advice about grooming and dental care for your puppy? *
Describe the problem, including when it started? *
Was there a recent change in environment before the problem started? *
Is this the first time your pet 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 or medical problems, including any medications they are currently taking. *
Do you have any questions for the vet which haven't been mentioned in the above history questions?
