New Patient FormName* First Last Name of Pet*Species*DogCatBreed*Color*Birth date/Approximate Age*Check all that apply* Male Neutered Female SpayedPet’s Temperament*AverageAffectionateCautionWill BiteFearfulEscape ArtistDoes your pet have insurance? If yes, what provider?Pet’s Favorite ToyPet’s Favorite TreatHas your pet had any allergies to food, vaccinations, or medication?Please check any symptoms or problems that you have with your pet that you'd like to discuss with the doctor Behavior Problems Lack of Appetite Sneezing Bleeding Gums Limping Thirst and/or Urination Increased Breathing Problems Loss of Balance Vomiting Coughing Scooting Weakness Diarrhea Scratching Eyes Bulging or Bloodshot Seems Depressed Gagging Shaking Head OtherPlease specifyHas your pet ever had a… (check all that apply) Dental cleaning Bad tooth or periodontal disease Hormone related disease (i.e. Hyperthyroidism) Nervous system disease Hypertension Bladder or other urinary tract disease Pancreatitis Liver disease Upper respiratory disease Gastrointestinal disease (vomiting &/or diarrhea) Allergies OtherPlease specify allergiesPlease specifyPet’s Current MedicationsAntibiotics (how many times per day)Steroids (how many times per day)Other (how many times per day)Other (how many times per day)Describe your Pet’s Diet*Other CommentsRECORD RELEASEBy signing below, I authorize Pinebrook Animal Hospital to release my pet’s medical and vaccine records, if requested by another veterinarian, boarding facility or grooming facility. (Signature)*Name* First Last NameThis field is for validation purposes and should be left unchanged.
