New Patient Form – Canine/Feline - Britannia Kingsland Veterinary Clinic

Owner's Name *

Phone Number *

Email *

Pet's Name *

Birthday *

Species *

Breed *

Colour and identifiable markings *

Sex *

Does your pet have any identification? *

Tattoo
Microchip
Neither - No permanent ID
Unsure if my pet has any permanent ID

Does your pet have pet insurance? *

Name of insurance company & policy number?

What brand of pet food do you currently use? *

Please list most recent vaccines & the date given. *

Has your pet had any recent medical problems? If yes, please explain.

Has your pet had any chronic or ongoing medical problems? If yes, please explain.

Does your pet have allergies? If yes, what is the suspected allergy? *

Has your pet had any lab work (blood/urine) done in the last year? *

Has your pet been tested for intestinal worms in the last year? *

Has your pet been tested for heartworm in the last year? *

Is your pet on heartworm or tick medication? If yes, please list. *

Does your pet go hiking, camping or hunting with you? *

Does your pet go outdoors? *

Is your pet overweight? *

Does your pet get treats? *

Does your pet get table food? *

Has your pet had a dental cleaning in the last year? *

New Patient – Canine/Feline