New Pet Questionnaire





Client First and Last Name:
Spouse / co-parent name:
Pet’s Name:
Home Phone:
Work Phone:
Contact Phone:
Address:
Occupation:
Email:
Species:
Breed:
Sex:
Neuter/ Spay
Color:
Date of Birth:
Microchip#:
Where was your Pet Born?
Where did you acquire your pet?
What do you feed?
Times/Day:
How often do you Wash the Food & Water Bowls?
Do you feed your pet “People Food”?
What?
What does your pet chew on?
Toys:
Where does she/he sleep?
Where does he spend the Day?
Where does he spend the Night?
What do you do to control Fleas?
Do you ever see Ticks in your yard or on your pet?
Do you take the pet Hiking or Camping?
If your pet is a cat, is he/she declawed?
Do you expect your pet to be a
Are there Other Pets in the household?
Dogs#
Cats #
Other #
Are there Stray Domestic Animals in the neighborhood?
Are there Wild Animals that come through your neighborhood?
Are there any problems with Aggression, Cowering, Urinating, Defecating or other
Behavioral Problems that you would like to discuss?

Permission to obtain previous medical records?

Clinic Name:

Phone:

Check to confirm submission.

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