PET INFORMATION FORM


Pet’s name__________________________  Species (cat/dog/bird?) _________________
Breed_______________________  AKC Registration number (if any)_______________
Sex:  Male or Female?        Neutered or Not?     If neutered, 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_______________________
                                                      Rabies_______________________
                                                      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