856.751.2122
Animal & Bird Health Care Center
Home
Doctors
Dr. Kenneth Dazen
Dr. David S Kupersmith
Dr. Jennifer Cromwell
Dr Stefan Gallini
Dr. Geraldine Kaufman
Dr. Mike Miller
Staff
Services
Wellness & Vaccine: Dog & Cat
Avian Health Care
Small Mammal
Reptile
Radiology
Surgery
Anesthesia
Microchipping
Dentistry
Laser Therapy
Online Store
Forms & Links
Forms
>
New Client Form
Avian History Form
Dog/Cat History Form
Ferret History Form
Reptile History Form
Small Mammal History Form
Boarding Form
Resources
Pictures
Our Pets
In Memory
New Page
Home
Doctors
Dr. Kenneth Dazen
Dr. David S Kupersmith
Dr. Jennifer Cromwell
Dr Stefan Gallini
Dr. Geraldine Kaufman
Dr. Mike Miller
Staff
Services
Wellness & Vaccine: Dog & Cat
Avian Health Care
Small Mammal
Reptile
Radiology
Surgery
Anesthesia
Microchipping
Dentistry
Laser Therapy
Online Store
Forms & Links
Forms
>
New Client Form
Avian History Form
Dog/Cat History Form
Ferret History Form
Reptile History Form
Small Mammal History Form
Boarding Form
Resources
Pictures
Our Pets
In Memory
New Page
Dog/Cat History Form
*
Indicates required field
Name
*
First
Last
Email
*
Pet's Name
*
This pet
*
is a new patient
has been seen before
Species
*
Date of Birth
*
Gender
*
Male
Female
Male Neutered
Female Spayed
Breed
*
How long have you owned your pet?
*
Do you have previous medical records?
*
Yes
No
If you do have previous records, please have them forwarded to us
Vaccine History
Please list the dates of your pets most recent vaccinations
Dog
Distemper
*
Leptospirosis
*
Bordetella
*
Rabies
*
Lyme
*
Cat
Distemper (Feline Respiratory)
*
Rabies
*
Feline Leukemia
*
Medical History
What kind(s) of food and treats do you give your pet?
*
How often do you feed your pet,or is food left out free choice?
*
Do you use any nutritional supplements? Type?
*
Please list any previous medical problems
*
Has your pet recently been exposed to other animals? Boarding, Grooming, Dog Park?
*
Yes
No
Have there been any changes in the pet's enviroment?
*
Have you noticed any of the following?
*
Weight Loss
Weight Gain
Increased Appetite
Decreased Appetite
Anorexia
Vomiting
Increased Urination
Decreased Urination
Difficulty Urinating
Diarrhea
Constipation
Excessive Shedding
Hair Loss
Scratching
Skin sores, lumps
Difficulty Breathing
Coughing
Sneezing
Nasal or Eye Discharge
Decreased Activity
Anxiety
Lethargy
Head Tilt or Balance Isuues
Limping
Pain
Please check all that apply. You can described more fully in the space provided..
If you have noticed any of the problems in the list, please describe more fully here.
*
Thank you for taking the time to fill out this form. Having this information will allow you to get more out of your time with the doctor.
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