Medical Information & History Form Please enable JavaScript in your browser to complete this form.Owner Name *FirstLastDate *Pet's Name *Reason for today’s visit? *Has your address or phone number changed since your last visit? (Select all that apply) *Address ChangePhone Number ChangeNeitherAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneEmail *Have you been to The Erlanger Veterinary Hospital or Pet Resort recently? *YesNoAre you interested in pet insurance? *YesNoDoes your pet travel out of state? *YesNoIf so, where? *Do you board or groom your pet? *YesNoDo you brush your pet’s teeth? *YesNoWhat is your pet’s diet (Brand)? *Has your pet shown any of the following signs or symptoms? If yes, please check the symptoms:Unusual Body OdorsBad BreathShaking Head/EarsCoughingSneezingWheezingGaggingChokingItchingHair LossSkin ProblemsPoor Hair/CoatVomitingDiarrheaScooting Rear EndLumpsBumpsLimpingLamenessStiffnessListlessWeaknessSeizuresUnusual DischargeSquintingExcessive PantingTremorsHas your pet shown significant changes in any of the following? (Please check all that apply)Character of bowel movements? Frequency or amount of urination? Weight gain or loss?Appetite?Drinking?Behavior?Digital Signature *Clear SignatureEmailSubmit