Animal Doctor Westside Your Other Family Doctor ADR First name * Last name * Preferred contact number. * Patient name * NEW PATIENTS ONLY: How long have you had the patient? NEW PATIENTS ONLY: Where did you get him/her? NEW PATIENTS ONLY: Is the patient microchipped? Yes No Unsure NEW PATIENTS ONLY: Vaccination history (be specific) NEW PATIENTS ONLY: Does the patient have any underlying conditions? Yes No Unsure NEW PATIENTS ONLY: If yes, please explain. What changes have you noticed? * How long have you noticed the change? * Is your pet experiencing (check all that apply): * Coughing Sneezing Lethargy Vomiting Diarrhea None of the above Briefly describe his/her appetite, thirst, and urination. * What kind of food are you feeding? How much per day? Table scraps/ treats? * Has your pet been in contact with other animals? * Yes No Unsure CATS ONLY: How often does your cat go outside? Does he/ she go outside on a leash or on a screened in porch? Could your pet have ingested anything abnormal? If so, what and how much? * Have you tried anything at home? Please explain if yes. * Is the patient on any medications? Include dosage and frequency. * Are you administering flea/ tick preventative? What type and how often? * Are you administering heartworm preventative? What type and how often? * Do we have permission to perform radiographs, bloodwork, or any additional diagnostics? * Yes No Unsure Do you have any additional questions or concerns you would like to address with the Doctor today? * Submit If you are human, leave this field blank.