Dogs and Cats Information Form in Laporte, CO

Animal's Name
Species (Dog or Cat)
Breed
Color
Age
Date of birth
MM slash DD slash YYYY
Male or Female
Spayed or neutered?
Date of last vaccination:
Distemper
Rabies
Kennel Cough
Fel.Leukemia
Leptospirosis
Other(please specify)
Date of last stool sample and/or deworming
Wormer used
Does your dog or cat hunt or eat dead rodents or other animals?
ls your dog on heartworm preventative? lf yes, which one
When did you give the last dose?
Date of last heartworm blood test
Has your pet ever lived in another state or country? lf so, where and when?
Has your animal had any previous illnesses or ongoing problem? Please describe
ls your animal on any supplements(including herbal and natural) or prescription medications? lf so which?
What brand and type(canned or dry) of food does your dog/cat eat?
How long has he/she been on this particular food?
lf changed within last month or two, what was previous type of food?
How many cups of dry per day?
How many cans per day?
Fed how many times per day?
Previous surgeries (approximate dates)
Reason for your visit today
Does your pet live

Dogs and Cats Information Form