Client Name *

First

Last

Primary Phone Number *

Email *

Secondary Contact *

First

Last

Secondary Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Previous Veterinary Records

Do you have your pet’s medical history? *

Yes, I have my pet's medical history.
No, my pet has never been to a vet before.
No, I do not have my pet’s medical history.

We'd be happy to help consolidate your pet's medical history. Are there any veterinary clinics that your pet has been to that we can call for records?

Name of Clinic

Phone Number

Address of Clinic

Address Line 1

Address Line 2

City

State

Zip Code

Would you like to add another veterinary clinic?

Yes
No

Name of Clinic

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Would you like to add another veterinary clinic?

Yes
No

Clinic Name

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Please upload any medical history documents: *

Click or drag files to this area to upload. You can upload up to 8 files.

Pet Information

Pet's Name *

Age *

Species *

Sex *

Breed *

Color *

Any medical allergies? *

History of adverse reactions after receiving vaccines (facial swelling, vomiting, diarrhea, Hives, Difficulty Breathing, collapsing) *

Yes
No

Current medications/treatments *

What best describes your pet's lifestyle? *

Strictly Indoors
Primarily indoors with some outdoor activities
Primarily outdoors with some indoor activities
Strictly outdoors

Microchipped *

Y
N

Reason for Visit *

Does your pet show any reluctance to getting in the carrier or car? *

Yes
No

How would you describe your pet's behavior during travel? (select all that apply) *

Eager & excited
Subdued/more quiet than usual
More vocal than usual

Does your pet do any of the following during travel? (select all that apply) *

Are there any situations that your pet has tried to avoid or seemed to dislike in the past? (select all that apply) *

If you chose other, please explain: *

Has your pet ever been prescribed any medications to help manage their fear or anxiety associated with the visit? *

Yes
No

If so, what was the medication and dose, and what sort of results did you experience? *

Do you think that your pet would benefit from medication to help manage their fear or anxiety around their upcoming vet visit? *

Yes
No
Maybe

Your Loving Vet In Portland, OR

New Patient Form

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New Patient Form

Previous Veterinary Records

Pet Information

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