Dog or Cat Exam 
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Phone Number  *
Pet's Photo (optional)
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Date
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Pet's name *
Owner's Name (First and Last) *
Date of Birth or Approx Age  *
MM
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DD
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YYYY
Sex of  pet  *
Required
Best Way to reach you after exams for updates or for lab results *
Are there any other family members or people that you would like to add to your pet's account. Please add if these people would be able to approve medical decisions for your pet.  *
Do you have medical insurance for your pet? *
If yes, What insurance company does your pet have?  *
Reason for visit today *
Is there anything additional that you would like to address in today's visit?
Has your pet been seen by previous Veterinarians?
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If "yes", which veterinary facilities has your pet been to?
My pet is  (check all that apply) 
My pet's stool is 
Urination Frequency
Urination
Water intake (thirst) 
Diet: please list all foods and treats given to your pet
Appetite
Medications Please list all medications, dosages, and when they were last given. 
Supplements: please list supplements, how much is being given, and when they were last given. 
How is your pet during veterinary exams?  *
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Is there any additional information that would be helpful for us in your pet's visit? 
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