New Pet Information

Pet's Name

Age / DOB

Species

Breed

Color

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Previous Veterinarian/Clinic

Approx. date of last vaccinations (mo/yr):

Example: 07/2022

Vaccinations received (please check all appropriate):

Rabies (Dog/Cat)

Distemper (Dog)

Parvo (Dog)

Corona (Dog)

Bordetella (Kennel Cough) (Dog)

Leptospirosis (Dog)

Influenza H3N8 (Dog)

Influenza H3N2 (Dog)

VS-Calici (Cat)

FIV (Cat)

Rabies (Ferret)

Distemper (Ferret)

Is your pet on heartworm preventative?

Yes

No

I don't know

If so, which?

Interceptor

Sentinel

Trifexis

Heartgard

Other

Approximate date of last Heartworm Test

Approximate date of last fecal exam

Other important medical history (allergies, diseases, surgery, etc.)

Does your pet have a microchip?

Yes

No

Microchip Number

Name

Species

Name

Species

Name

Species

We will not start records on these other animals from this list. It is simply to help us keep families of pets together. If you would like us to start medical records on your other pets, please fill out a sheet on each. If you have the vaccination dates, we can remind you when they are due.

I do hereby give Creekside Animal Hospital permission to obtain copies of my pet's medical records.

Photo Release Authorization

I grant to Creekside Animal Hospital, its representatives and employees, the right to take photographs of my pet(s), and to copyright, use and publish the same in print and/or electronically. I agree that Creekside Animal Hospital may use such photographs of my pet(s) with or without their name, or mine, and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.

Yes

No

New Pet Information

Patient Information:

Pet's Name

Age / DOB

Species

Breed

Color

Sex

Medical History

Previous Veterinarian/Clinic

Approx. date of last vaccinations (mo/yr):

Vaccinations received (please check all appropriate):

Is your pet on heartworm preventative?

If so, which?

Approximate date of last Heartworm Test

Approximate date of last fecal exam

Other important medical history (allergies, diseases, surgery, etc.)

Does your pet have a microchip?

Microchip Number

Other Pets in the Household

Name

Species

Name

Species

Name

Species

Consent

We will not start records on these other animals from this list. It is simply to help us keep families of pets together. If you would like us to start medical records on your other pets, please fill out a sheet on each. If you have the vaccination dates, we can remind you when they are due.

Pet Photo Release

Photo Release Authorization