Hospital and Clinic
12462G Natural Bridge Rd.
Bridgeton, MO 63044
(314) 739-1510
Toll Free: 1-877-VET-SPEC 1-877-838-7732

 
Hospital and Clinic
12462G Natural Bridge Rd.
Bridgeton, MO 63044
(314) 739-1510
Toll Free: 1-877-VET-SPEC 1-877-838-7732

 
Hospital and Clinic
12462G Natural Bridge Rd.
Bridgeton, MO 63044
(314) 739-1510
Toll Free: 1-877-VET-SPEC 1-877-838-7732

PROVIDING ADVANCED VETERINARY CARE
 
  Client & Patient Information

 

You may download this form in PDF format and bring it with you, or you may e-mail the form by clicking on the red box at the end of the form.
Please fill in the appropriate fields.

Date:
Mr.  Mrs.  Ms.  Dr. 
Have you been to this office with any other pet?    YES    NO
Last Name:    
First Name: 
Spouse/Other: 
Address: 
City:    State:    Zip Code: 
Home Phone:    Business Phone: 
Cell/Pager Number: 
Email: 
Place of Employment: 
Referring Veterinarian's Name: 
Referring Veterinary Hospital: 
Spouse's Place of Employment: 
Spouse's Business Phone: 
Driver's License Number: (For ID Purposes)
Pet Name:    Dog   Cat
Breed:
Sex:     Male     Male(Neutered)     Female     Female(Spayed)
Date of Birth:    Allergies:
Color:
Please give approximate dates of the following routine medical care:
DOGS
HeartwormTest:
Heartworm Preventative: Yes  No
Distemper Vaccine:
Rabies Vaccine:
CATS
Feline Leukemia/FIV:
Leukemia Vaccine:
Distemper Vaccine:
Rabies Vaccine:
• Do you have pet health insurance?     YES    NO

• Where did you obtain your pet?

• How long have you owned your pet?

• Where is your pet housed? Indoors Outdoors
  Both Other
• Intended purpose of your pet? Pet         Show Sport
  Guard Other

• For intact females, when, approximately was your pet’s last heat cycle?

• For neutered/spayed pets, when, approximately, was the surgery performed?

• What is your pet’s current diet? (include brand)

• Does your pet have any food allergies? YES NO

• Has your pet had any bad reactions to a medication?

YES NO
• Does your pet have contact with other animals? YES NO

• Is your pet microchipped?

YES NO

• Has your pet ever been out of the St. Louis Metro Area?

YES NO
If yes, please indicate where below:
• Is your pet currently receiving any medications? YES NO
Please list medication Below

• Has your pet had any illness, injury, or surgery prior to the current problem? Explain Below

YES NO
•Is your pet currently coughing or sneezing? YES NO
• Has there been a recent change in your pet’s appetite? YES NO
• Has your pet lost or gained weight recently? YES NO
• Is your pet currently vomiting? YES NO
• Has there been any recent change in your pet’s bowel movement? YES NO
• Have there been any recent changes in your pet’s urinary habits? YES NO
• Have you noticed a change in the amount of water your pet drinks? YES NO

• What is the date of your pet’s appointment?