New Client (Dog)"*" indicates required fields Date* MM slash DD slash YYYY Owner Name*PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Pet Name*Breed*Color*Age / Birthdate*Sex* Male (intact) Male (neutered) Female (intact) Female (spayed)About Your DogYour dog was obtained from:* Breeder Pet store Friend Stray Humane Soc. OtherYour dog is:* Indoor Outdoor Both# of dogs in Household*Brand of pet food:Canned / Dry* Canned DryHow is your dog's appetite Normal OtherHow is your dog's attitude: Happy-active-normal Depressed-lethargic OtherIs your dog drinking?* Normally More Less than usualDo you notice any of the following: Limping Eye Discharge Nasal Discharge Sneezing Coughing Shaking head Scooting Scratching Vomiting Diarrhea Lumps Bad breath often Weight loss Lethargy / Weakness Seizures Hair loss pain or straining when urinating / defecatingYour Dog's Medical HistoryPrevious Veterinary HospitalAttach records from you previous vetMax. file size: 250 MB.May we request your records from their office? Yes No First visit to a veterinarianHas your dog had the following in the last 12 monthsPhysical Examination* Yes No UnsureDate* MM slash DD slash YYYY Dental examination AND cleaning* Yes No UnsureDate* MM slash DD slash YYYY Heartworm test* Yes No UnsureDate* MM slash DD slash YYYY Fecal Sample Test* Yes No UnsureDate* MM slash DD slash YYYY Blood testing for thyroid, kidney & liver function* Yes No UnsureDate* MM slash DD slash YYYY Has your dog been vaccinated for the following in the last 12 months:Rabies* Yes No UnsureDate* MM slash DD slash YYYY Canine Dystemper* Yes No UnsureDate* MM slash DD slash YYYY Lyme Disease* Yes No UnsureDate* MM slash DD slash YYYY Canine Cough* Yes No UnsureDate* MM slash DD slash YYYY Dewormed* Yes No UnsureDate* MM slash DD slash YYYY Flea & tick preventative(s)Collar / None?* Collar NoneHeartworm PreventativeCollar / None?* NoneAre you familiar with geriatric care for dogs over 7 years of age?* Yes NoCurrent MedicationsAllergiesComments
