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Today’s Date: Client Name: Client Number:
WELCOME TO ALL CREATURES ANIMAL CLINIC, LTD.
Thank you for entrusting your companion to our care.
PET INFORMATION
Name of Pet: Dog Cat Other Lives: Indoor Outdoor
Sex: Male Female Neutered Spayed Pet’s Birthdate or Approximate Age:
Breed: Color: Tattoo/Microchip ID #:
At what age was pet obtained:________ Obtained from: Breeder Shelter Individual Stray
Reason for obtaining pet: Companion Breeding Protection Hunting
Pet’s Diet: Current Medications:
Will your pet be boarded? Yes No Will your pet be around other animals? Yes No
The reason for today’s visit:
Do you grant consent to release pet records and/or your contact information to anyone requesting this information? Yes No (i.e.: boarding/grooming facilities, humane societies or shelters, any individual who might find your pet if lost.)
Do we have permission to post photos to our clinic social media formats (i.e.: Facebook)? Yes No
Please check any symptoms or problems you’ve noticed with your pet:
Appetite Loss Depression Limping Thirst Increased
Bad Breath Diarrhea Loss of Balance Urination Increased
Behavioral Changes Eye Problems Scooting Vomiting
Breathing Problems Gagging Scratching Weakness
Coughing Gums Bleeding Shaking Head Weight gain or loss
Dental Problems Hair Loss Sneezing Fleas, ticks
PET HISTORY Please list approximate date of last vaccination and/or procedure:
Canine Date Feline Date
Parvo/Distemper Vaccination FVRCP Vaccination
Rabies Vaccination Feline Leukemia Vaccination
Bordetella Vaccination Rabies Vaccination
Lyme’s Vaccination FIV Vaccination
Heartworm Testing Feline Leukemia Test
Heartworm Preventive FIP Test
Dental Cleaning Dental Cleaning Prior Illness Prior Illness
Prior Surgery Prior Surgery
Flea/Tick Control Flea/Tick Control
Internal Parasite Control Internal Parasite Control
Entered by: (ACAC Staff)
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