PET INFORMATION FORM



Pet’s name Species (cat/dog/bird?) 

Breed AKC Registration number (if any)

Sex: Male or Female?  Neutered or Spayed? 

If neutered or spayed, at what age?  

Microchip or Tattoo number if present. 

Date of Birth OR Approximate Age 

Description of your pet:

Do you have a copy of the pet’s medical record with you? 

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


Cats Dogs

Rhino, Calici, Panleukopenia  Distemper, Parvo

Feline Leukemia   Bordetella 

Feline Immunodeficiency   Lyme’s Disease  

Rabies   Giardia  Leptospirosis


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


To Dr. 


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


________________________________ __________________

(Owner’s signature) (Date)


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 (1-11)


Does your pet come into contact with other pets or their environments? Yes No (1-3, 5-11)


Is there wildlife in your area, including mice, squirrels, birds, possums, raccoons or skunks? Yes No (2-6, 7)


Are there ticks in your area? Yes No (4)


Do you travel with your pet to coastal areas where ticks or mosquitoes may be present?

Yes No (4)


Does your pet have the opportunity to drink from standing water outdoors (ponds,

puddles, etc.)? Yes No (3, 5)


Does your pet sleep with you or your children? Yes No (3, 5, 7)


Do you ever take your pet to a groomer or boarding facility? Yes No (1, 2, 5, 6, 8, 9, 10)


Do you ever take your pet to cat or dog shows? Yes No (1, 2, 5, 6, 8, 9, 11)


If you have a dog, do you ever take it hunting? Yes No (1-5, 7)


The numbers associated with each yes answer corresponds to the recommended immunizations listed below.


  1. Canine Parvovirus

  2. Canine Distemper, Adenovirus, Parainfluenza

  3. Leptospirosis

  4. Lyme Disease

  5. Giardia

  6. Bordetella bronchiseptica (Kennel Cough)

  7. Rabies

  8. Feline Panleukopenia Virus

  9. Calicivirus, Rhinotracheitis

  10. Feline Leukemia, Feline Immunodeficiency Virus

  11. Feline Infectious Peritonitis


NOTICE:  If you have a Religious Objection to vaccines, then please notify your Vererinarian.  Note:  THE STATE OF IDAHO requires all dogs and cats over the age of sixteen (16) weeks to have a rabies vaccination, and the vaccination must be kept current.