LVCC Patient Information Form Name of Pet * Type of Pet * Dog Cat Other Male Female Spayed/Neutered Breed of Pet Date of Birth MM DD YYYY AGE Color of Pet How long have you had your pet? Purpose of visit? * Check any of the following if present: Appetite Loss Diarrhea Vomiting Lameness Scratching Sneezing Coughing Loss of Energy Weight Loss Behavioral Issues Please list any other issues: MEDICAL & BEHAVIORAL HISTORY Previous veterinarian, if any: List existing or previous medical conditions: List any current medications being given to the above pet: DIET: What is offered and what is eaten (include brand names, amount fed, and frequency of feeding)? FAMILY SETTING Is your pet house… Inside Outside Alone With Others Is your pet on heartworm preventative? Yes No Is pet on flea & tick control? Yes No Is your pet current on vaccination? Yes No Unsure Owner Name First Name Last Name Email Date MM DD YYYY Thank you! We will email you if we have any questions.
