Welcome to Ad Park Pet Clinic

Client Information									Date________________

Name_____________________________________________________ Home Phone (_____)__________________

Address____________________________________________________ Work Phone (_____)_________________

City, State, Zip_____________________________________________  Cell Phone  (_____)___________________

Emergency Contact Name_______________________________________  Phone (_____)____________________

How did you learn about our practice?______________________________________________________________

Number and type of pets_________________________________________________________________________

Primary reason for visit__________________________________________________________________________

Pet Information				

Pet’s Name__________________________________________________		Dog _____	Cat _____

Sex:     M _____     F _____        Age_______ Birth Date___________________ Breed_________________________________________

Color__________________________________________     Neutered/Spayed:     Yes _____     No _____     At what age? _____________

At what age was pet obtained?________________     From whom?____________________________________

List your pet’s recent medications____________________________________________________________________________________

Please check any symptoms or problems you have noticed with your pet:

___ Appetite Loss		___ Gagging			___ Sneezing 		___ Thirst			
___ Behavioral Changes	___ Gums Bleeding		___ Limping		___ Urination Increase 
___ Breathing Problems	___ Loss of Balance		___ Scooting		___ Vomiting
___ Coughing			___ Depression		___ Scratching	___ Weakness
___ Diarrhea			___ Shaking Head		___ Eye Disorders	___ Any Lumps or Bumps
___ Other ____________________________________________________________________________________

Pet’s History (check all that pet has received):
		                 Date			    		  Date
___ Distemper             _________	   ___ Feline Leukemia Test  _________  	___ Surgery _________________
___ Parvovirus (dog)   _________	   ___ FVRCP (Cat)               _________	___  Illness__________________
___ Rabies (dog/cat)   _________         ___ Dental		           _________       ___ Other __________________
___ Allergies to medicines or vaccines (explain) ______________________________________________________

Authorization - I hereby authorize the veterinarian to examine, prescribe for, or treat my pet. I assume 
responsibility for charges incurred for the care of my pet. I understand that 
ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

Signature ______________________________________________________        Date _______________________