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Pet Intake Form
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1. Basic Pet Information
Client Full Name:
*
Phone
*
Email
*
Pet's Name
Animal Type (Dog, Cat, Llama, etc.)
*
Male
Female
Spayed
Neutered
Approx. Age at Spay/Neuter:
Approx. Age Now:
Birth Month/Year (if known):
Had pet since birth
Did not have since birth
If no, since when?
Circumstances of acquisition:
2. Vaccination History
List any and all vaccines you recall:
List any problems or reactions following vaccines:
3. Medication History
List any medications your pet has been given:
List any medication reactions you recall:
or animals
4. Health History
List any noted illnesses, traumas, or surgeries:
Explain details (dates, circumstances, outcomes):
5. Primary Concerns
1. Concern:
Visible symptoms:
2. Concern:
Visible symptoms:
3. Concern:
Visible symptoms:
6. Eating Habits
Type of food:
Good Eater
Picky Eater
Other
Additional notes on appetite or digestion:
7. Social & Emotional Environment
Other people or animals in the pet’s lifetime:
Loss of other people or animals that may have impacted your pet:
Relationship issues in the home (if any):
Who is the pet closest to?
Who is the pet most distant from?
Gets along with other pets
Does not get along with other pets
If no, please explain (jealousy, anger, fear, aggression, sadness, or other):
8. Physical Condition
Overweight
Underweight
Average weight
List any diagnoses or medical conditions:
Additional Notes
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