Pioneer Veterinary Hospital New Client Form

Pioneer Veterinary Hospital New Client Form
Bird

Pod Pocket Pet
Pets Name:
Species

CatDog
Sex

MaleFemale
Spayed/Neutered

YesNo
Breed
Color/Markings
Date of Birth

MonthDayYear
Date
Age (if birthdate unknown).
Vaccination/Medical History

Canine (Please specify dates below if known)
DHPP: Commonly known at a "Distemper Vaccine”. This combination vaccine consists of Distemper, Hepatitis, Parvovirus, and Parainfluenza inoculations. Rabies: This vaccine can be on an annual or every three-year schedule. This vaccine is required by law.

YesNoType option 4
Date

MonthDayYear
Date
Lepto: Leptospirosis may be given in conjunction with the distemper vaccine or as a single annual vaccine when the DHPP is on a three year schedule.

YesNo
Date

MonthDayYear
Date
Bordetella: Commonly known as "kennel cough”. Grooming and kennel facilities are high risk environments for these contagious organisms.

YesNo
Date

MonthDayYear
Date
Fecal Exam:

NegativePositive
If positive, please specify
Heartworm Test:

YesNo
Recommended annual blood test.
Feline (Please specify dates below if known)
FELV: Feline Leukemia. May be given in conjuction with the FVRCP vaccine on an annual or every three year schedule.

YesNo
Rabies: This vaccine can be on an annual or every three year schedule. This vaccine is required by law.

YesNo
FVRCP: Commonly known as a "Distemper Vaccine". This combination vaccine includes Panleukopenia, Calici virus, and Rhinotracheitis

YesNo
FELV Test: (Feline Leukemia)

NegativePositive
Fecal Exam:

NegativePositive
If positive, please specify
Is your pet on any flea and/or heartworm prevention?

YesNo
If so which kind? /
Last given:

MonthDayYear
Date
Is your pet on any prescribed or over the counter medications (i.e. Vitamins, worming medication, other)
Do you board your pet when you are away?

YesNo
What percentage of the time does you pet spend outside?
Describe your pet's diet
Microchip Number:
Should be Empty: