Pet Owner Information
Pet Information
Is your pet a dog or a cat?
Is your pet a male or female
Has your companion ever shown aggressive behavior?
Any coughing or sneezing?
Any increase or decrease in urination?
Any increase or decrease in water intake?
Has your pet had an increase or decrease in appetite?
Has your pet had any vomiting or diarrhea?
Does your pet have any pre-existing medical problems or history of transfusion?
Is your pet currently on any medications?
Is your pet current on vaccines?
Does your pet have any history of vaccine reactions?
Does your pet have any food/medication allergies?
Has your pet had any recent boarding or contact with another pet outside your home?
Is your pet spayed/neutered?
Are there any procedures your pet has not liked having performed in the past (nail trims, blood draws, weight, temperature)?
Has your pet been prescribed supplements or medications to decrease anxiety associated with a veterinary visit?
Is your pet currently on Heartworm Prevention?
Is your pet currently on Flea and Tick Prevention?
If a feline:
Does your pet share the house with any other cats or dogs?
In the event of an emergency would you like CPR if your pet requires resuscitation?
I understand that payment is expected at time of service & I agree to pay for all services at the time they are rendered:
Do you grant Count Line Veterinary Clinic permission to post your pet’s (s’) picture and story on our website and or social media?
Terms and Conditions
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