New Patient Form – Middle Creek Veterinary Hospital

Getting to Know Your Pet

Species*

Canine (Dog)
Feline (Cat)

Patient Name*

Owner Name*

First Last

Nickname (if applicable)

From where and when did you acquire this animal?*

Date of Birth (if known)*

Age (or approximate)*

Gender*

Male
Female
Spayed (Females)
Neutered (Males)

Breed*

Is your pet*

Purebred
Mixed
Unknown

Color and Markings*

Previous Veterinarian

Has this animal previously been to a veterinarian?*

Yes
No

Last Visit (or approx.)*

Name and Location (city, state) of Previous Veterinary Hospital(s) and Veterinarian(s) (if specific):*

Do you have copies of your pet’s full medical record? (If yes, please email copies prior to appt.)*

Yes
No

Would you like for us to contact your previous veterinarian to get your records transferred?*

Yes
No

Medical History

List any relevant medical conditions that your pet was PREVIOUSLY treated for but is no longer receiving treatment. This may include conditions such as surgeries, injuries, or illnesses that do not require lifetime therapy.*

List any CURRENT diseases or diagnoses that your pet has and is being treated for.*

List any medications or supplements that your pet is currently being given, including dose, frequency, and length of treatment. Please also include supplements such as vitamins, glucosamine. (Ex: carprofen 25mg, 1/2 tablet morning and night, has been taking intermittently since February 2011):*

Please BRIEFLY describe any additional concerns that you would like to specifically address during your visit.*

Has your pet ever had a severe allergic reaction?*

Yes
No

If yes, please describe

Home Life

What is the primary purpose of this pet?*

Companion to Humans
Companion for Other Pet(s)
Protection of Person/Property
Service Animal
Emotional Support
None

Where does this pet spend their time?*

Approximate number of hours spent outside daily*

What is your pet’s average activity level?*

Highly Active (hiking, running, working, swimming, long periods of play, an hour or more daily)
Moderately Active (frequent walks, running errands with family, daily play time, between 30 min to 1 hr daily)
Lightly Active (occasional walks, play times, less than 30 min daily)
Couch Potato (as little activity as possible)

What other pet(s) are in the home? Does this pet have any interaction with the others?*

Food and Diet

What does this animal eat? (Check all that apply):*

What is the brand and type/flavor of food that your pet eats? What amounts of each type of food does your pet eat and how often? Please be as SPECIFIC as possible. We use this information when we calculate calories and create diet plans.*

Other Facts, Quirks, and Preferences

Does your pet have any behavioral issues (barking, separation anxiety, destroying things, etc.)?*

Yes
No

If yes, please list or briefly describe

Is your pet generally food motivated?*

Yes
No

Are there any favorite foods/treats that we can use to help your pet have a good experience during their visit?*

Are there any places that your pet HATES to have touched (ears, feet, etc.)?*

Yes
No
Don't Know

If yes, which area(s)?

Has your pet ever bitten or scratched someone during a veterinary visit?*

Yes
No

If yes, do you know why (pain, fear, mishandling, etc.)?*

Is there anything else that you would like us to know before your visit today?*

Monday	9:00am – 5:00pm
Tuesday	10:00am – 7:00pm
Wednesday	9:00am – 5:00pm
Thursday	10:00am – 7:00pm
Friday	9:00am – 5:00pm
Saturday	By Appointment Only
Sunday	Closed

Canine or Feline New Patient Information

Getting to Know Your Pet

Previous Veterinarian

Medical History

Home Life

Food and Diet

Other Facts, Quirks, and Preferences

Contact Us

Hours of Operation

Emergency Info