Associated Veterinary Specialists
About
Services
Client Handouts
Referring Vet Login
Contact
New Patient
Back
Doctors
Location
Back
Internal Medicine
Diagnostic Imaging
Minimally Invasive Procedures
Hyperthyroidism in Cats
About
Doctors
Location
Services
Internal Medicine
Diagnostic Imaging
Minimally Invasive Procedures
Hyperthyroidism in Cats
Client Handouts
Referring Vet Login
Contact
New Patient
Associated Veterinary Specialists
Have you been to this office with any other pet?
*
Yes
No
Primary Contact
*
First Name
Last Name
Preferred Pronouns
He/Him
She/Her
They/Them
Ze/Zir
Secondary Contact
First Name
Last Name
Preferred Pronouns
He/Him
She/Her
They/Them
Ze/Zir
Street Address
*
City/State/Zip Code
*
Primary Phone
*
Home/Other
Secondary Phone
Email Address
*
Referring Veterinarian's Name
Referring Veterinary Hospital
Any Other Veterinary Facilities Visited
Date of Appointment
MM
DD
YYYY
Pet's Name
Dog
Cat
Male
Male Neutered
Female
Female Spayed
Breed
Color
Date of Birth
Is your pet current on all vaccines?
Feline Leukemia/FIV Test Results
Do you have pet insurance?
*
Yes
No
Supplier/Policy Number:
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
Don't know
Has your pet had any bad reactions to a medication?
Yes
No
Don't Know
Does your pet have contact with other animals?
Yes
No
Don't know
Has your pet ever been out of the St. Louis Metro area?
Yes
No
Don't know
Is your pet currently receiving any medications? Please list below.
Yes
No
Don't know
Medications:
Has your pet had any illness, injury, or surgery prior to the current problem? Explain below.
Yes
No
Don't know
Previous issues:
Is your pet currently coughing or sneezing?
Yes
No
Don't know
Has there been a recent change in your pet's appetite?
Yes
No
Don't know
Has your pet gained or lost weight recently?
Yes
No
Don't know
Is your pet currently vomiting?
Yes
No
Don't know
Has there been any recent change in your pet's bowel movement?
Yes
No
Don't know
Has there been any recent changes in your pet's urinary habits?
Yes
No
Don't know
Have you noticed a change in the amount of water your pet drinks?
Yes
No
Don't know
Any additional comments, concerns, or information you want us to know:
Thank you!