Holland Lake - New Patient Information Form

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New Patient Information Form

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Pet's Information

Pet's name

Species: (dog, cat, etc.)

Breed: (if known)

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Age

Years

Last Name

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Gender

Male

Male/neutered

Female

Female/spayed

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Medical History

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Please tell us about any past major medical conditions, injuries, or surgeries, etc. that your pet has experienced. If possible, include the approximate dates and what veterinary hospital provided the care

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Please list any medication and/or supplements your pet is taking. Include doses, & how often you give it

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Has your pet had any adverse reactions to medications or vaccinations? If so, please briefly explain below. Please include what drug/vaccination caused the reaction(s) and approximate dates they occurred

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Vaccination History

Below please enter the date (month/year) of the last time your pet received any of the vaccines below. If you have any printed vaccination records, please bring them with you on your first visit.

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Dogs (Dates of last vaccinations)

Rabies

DHPP (DA2PP)

Leptospirosis

Bordetella

Influenza

Other

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Cats (Dates of last vaccinations)

Rabies

FVRCP

Leukemia (FeLV)

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Preventative Healthcare

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What food are you currently feeding your pet?

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Are you currently giving your pet a heartworm preventative medication?

Yes

No

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If so, what is the name of the medication?

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Are you currently using a flea control product on your pet?

Yes

No

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If so, what is the name of the product?

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And finally…May we contact your previous veterinary office for past medical records?

Veterinary Hospital name

Phone

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Owner Email* This field is required.

example@example.com