Thank you for choosing our veterinary practice and for giving us the opportunity to care for your pet. We will treat your pet(s) as our family and provide the highest quality of care possible.

Please take time to fill out this form and to ensure all information is accurate and complete.

Owner Name *

First

Last

Owner Email *

Phone *

Pet Name *

Species *

Sex *

Intact Male
Neutered Male
Intact Female
Spayed Female

If Altered, year of procedure:

Age/Estimated Date of Birth *

Breed *

Color/Morph *

How long have you had this pet? *

How did you first acquire this pet? *

Has this pet ever been evaluated by a veterinarian before? *

If yes, by whom (include vet name and town of practice):

Date of last rabies vaccination: *

What other vaccines has your pet received? *

Does your pet have any current medical problems (i.e. heart murmur)? If yes, please describe: *

Does your pet currently take any medications/supplements (including flea/tick medications)? If yes, please describe what type, dosage, and frequency: *

What is going on that has brought you to see us? *

Is this a new problem? *

How long has this been going on? *

Is it constant or does it come and go? *

Have you given anything to treat this problem? If yes, please describe: *

Are there any other pets in your household that are experiencing similar problems? If yes, please explain: *

What does your pet normally eat? *

Kibble
Homecooked dog diet
Raw diet
Table food

What brand of food does your pet consume? *

How often and how much is your pet fed? *

Is your pet a picky eater? If yes, please explain: *

What kind of snacks does your pet receive? *

Does your pet chew on bones/rawhides/hard toys? If yes, please describe: *

Is your pet known to chew or ingest nonfood items? *

Would you describe your pet as having a sensitive stomach? If yes, please explain: *

Where does your pet spend most of their time?

Indoors
Outdoors
Both

Where does your pet eliminate waste?

Indoors
Outdoors

Is your pet permitted outside? If yes, please describe their outside environment (i.e. is it fenced, near woods): *

Where does your pet sleep? *

Is your pet exposed to other dogs by boarding or through grooming services? If yes, please explain: *

Does your pet travel (can be out of county, out of state, out of country)? If yes, describe: *

In the event that my pet's health were to decline, I acknowledge that Country Hills Veterinary Hospital would be permitted to start lifesaving measures to prevent loss of life. In the event this is unsuccessful and my pet's heart were to stop beating, I would like to: *

Decline cardiopulmonary resuscitation (CPR) measures, including chest compressions
Give permission for cardiopulmonary resuscitation (CPR) measures, including extreme measures

I hereby acknolwedge that I give Country Hills Veterinary Hospital consent to treat this animal and that I take financial responsibility for the care provided for this animal. *

Clear Signature

Date *

Payment in full is due at the time services are rendered
Only cash, credit cards, care credit or scratchpay are accepted as form of payment

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