Holistic Vet - Newmarket

PATIENT INTAKE FORM First time patient? Please fill out this form below well before your appointment to save time upon your arrival. Alternatively you will have to fill it out when you get here.
Animal's name
Date of birth
Breed
Colour
Sex
Neutered?
Owner's Name
Full Address (city, province, postal code)
Work Telephone
Home Telephone
Cell Telephone
Fax
Email Address
Number of people in household
Other Pets
Chief concerns in order of importance (include date of onset, treatments, medications, etc.)
List of current drugs/medications:
List of current supplements/natural remedies:
Name any of the following conditions your pet has now or had in the past: Abscess, allergies, anemia, appetite change, arthritis, asthma, autoimmune disease, bad body odor, bad breath, bladder infections/stones, behavior change, cancer, contagious disease, constipation, coughing, diabetes, diarrhea, ear infection, flatulence, fleas, gum/dental disease., heart disease, heart worm, hip dysplasia, itchy skin, itchy ears, joint pain, kidney disease, liver disease, low energy, parasites, seizures, skin/coat problems, tumors, urinary problems (increased frequency, difficulty urinating, blood in urine, urinating in unusual places), vomiting, warts, weight gain, weight loss.
List any condition(s) after which your pet has never been totally well:
List surgeries and injuries your pet had (include dates/age):
Vaccinations (include which vaccines/dates/age/date of last vaccination):
Any adverse effects from vaccine?
Pet’s current diet:
Last change in diet:
Other veterinarian(s) NAME CLINIC TEL NO
Has your pet received naturopahtic/homeopathic/chiropractic before (describe)?
Describe your pet’s temperament:
How does s/he react to veterinary examination? Friendly - Fearful - Gentle - Defensive - Protective of owner- May bite/scratch - Needs a muzzle - I’m unsure
Please list anything else you want us to know about your pet:
How did you hear about our office?