Patient/Owner Information Form Patient/Owner Information Form This form is also available as a fillable PDF. Download Patient/Owner InformationOwner's Name:* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Pet's Name:* Patient InformationSpecies: Dog Cat Breed: Age (D.O.B.): Sex: Male Female Status: Neutered Intact Status: Spayed Intact Colour: Do you have insurance for this pet? Yes No Please indicate: PetSecure Trupanion PetCare Origin: Breeder Store Shelter Origin Name and Location: Date: MM slash DD slash YYYY Owner / Primary ContactAddress: Street Address Unit # City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home#:Cell#:Work#:Email:*(so we can email you reports or information) Enter Email Confirm Email Additional Owner / ContactName: Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Does this person also have the decision-making authority? Yes No Relation to above: Home#:Cell#:Work#:Email: Enter Email Confirm Email Family Vet InformationYour regular veterinary hospital: Your veterinarian’s name: Have you been to our hospital before? Yes No Unknown With which pet? Professional fees are due at the time services are rendered. Surgery and hospitalization will require a deposit at the time of admittance. We accept cash, debit, Mastercard, VISA and AMEX. We do not accept personal or business cheques.Is your pet here for outpatient radiology? Yes. No. I am here for other services. Current DietRoutine: Free choice Set meals per day Please describe:Brand nameAmount/mealCanned or Dry?# Meals/day Any known food allergies/intolerance? Yes No Please indicate known allergies or allergen testing done:Vaccine HistoryLast vaccine given: Date: MM slash DD slash YYYY Travel HistoryPlease indicate location, approximate date and length of visit:Drug ReactionsPlease indicate any known adverse reactions/allergies to vaccines, oral medications, anesthetics and/or topical drugs or shampoos:Current MedicationPlease list all medications including topical medications, flea prevention and herbal/vitamin supplements:MedicationDosageFrequency Do you have any other pets at home? Yes No Has your other pet(s) been diagnosed with any types of illness recently? Yes No Medical HistoryHave you noticed any of the following in your pet:Change in water intake. Yes No How? Increased Decreased Total water intake: Change is: Measured Approximate Change in urination. Yes No Have you noticed any: Straining Blood Frequency: Vomiting. Yes No Please describe (i.e. bile/undigested food/blood) and include frequency:Diarrhea. Yes No Have you noticed any: Blood Mucus Frequency: Change in appetite. Yes No Change in body weight. Yes No Has your pet exhibited any other symptoms? Yes No Please describe behaviour changes:Has your pet recently had an X-ray? Yes No How long ago?Please list any previous medical problems:DateCondition