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Medical Information & History Form
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Owner Name
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First
Last
Date
*
Pet's Name
*
Reason for today’s visit?
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Has your address or phone number changed since your last visit? (Select all that apply)
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Address Change
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*
Have you been to The Erlanger Veterinary Hospital or Pet Resort recently?
*
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No
Are you interested in pet insurance?
*
Yes
No
Does your pet travel out of state?
*
Yes
No
If so, where?
*
Do you board or groom your pet?
*
Yes
No
Do you brush your pet’s teeth?
*
Yes
No
What 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 Odors
Bad Breath
Shaking Head/Ears
Coughing
Sneezing
Wheezing
Gagging
Choking
Itching
Hair Loss
Skin Problems
Poor Hair/Coat
Vomiting
Diarrhea
Scooting Rear End
Lumps
Bumps
Limping
Lameness
Stiffness
Listless
Weakness
Seizures
Unusual Discharge
Squinting
Excessive Panting
Tremors
Has 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?
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