Owner’s name*

Pet’s name* Species (cat/dog/bird?)* 

Breed AKC Registration number (if any)

Sex:* Male  Female    Neutered or Spayed?* Yes  No

If neutered or spayed, at what age?  

Microchip or Tattoo number if present. 

Date of Birth OR Approximate Age 

Description of your pet (Color and Markings):

Do you have a copy of the pet’s medical record with you?* Yes  No

If not, do you know when the pet was last vaccinated for:

If you would like us to request a copy of the pet’s previous medical history from another veterinary clinic, please provide a name address, and phone number then sign below.

To Dr. 

Your Name: 

Address: 

Phone Number: 

I, , the owner of the animal described above,

(print name)

Request that a copy of the pet’s medical record be sent to:

Eastgate Pet Clinic FAX (208) 336-5038

626 E. Boise Ave. Tel: (208) 336-3278

Boise, ID 83706-5118

I Agree

Does your pet have any medical or behavioral problems you are aware of? Any known reactions to medications or anesthetics? Is there anything special about this pet that we should be aware of?

When your pet goes outdoors, is it ever unsupervised?* Yes No

Does your pet come into contact with other pets or their environments?* Yes No

Is there wildlife in your area, including mice, squirrels, birds, possums, raccoons or skunks?* Yes No

Are there ticks in your area?* Yes No

Do you travel with your pet to coastal areas where ticks or mosquitoes may be present?*Yes No

Does your pet have the opportunity to drink from standing water outdoors (ponds, puddles, etc.)?* Yes No

Does your pet sleep with you or your children?* Yes No

Do you ever take your pet to a groomer or boarding facility?* Yes No

Do you ever take your pet to cat or dog shows?* Yes No

If you have a dog, do you ever take it hunting?* Yes No