Pet Health First Aid Dental Care Senior Pets Exotic Pets Puppies & Kittens	New Patient   Pet's Name: Pet's Birth Date: Species: Select Canine Feline Exotic Avian Breed: Sex: Select Male Male(neutered) Female Female(spayed) Color: Weight: Select Less than 80 pounds Greater than 80 pounds Owner's Name: Address: City:    State:  e-mail: Home Phone: Cell Phone: Emergency Contact Name: Emergency Contact Phone: Skin Condition: Chronic Health Problems:   Drug Sensitivity: Is your pet on medication?   Yes   No Medication 1: Dosage: 1 2 3 4 5 6 Times Daily Medication 2: Dosage: 1 2 3 4 5 6 Times Daily Medication 3: Dosage: 1 2 3 4 5 6 Times Daily   Is Your Pet on a special diet? Yes   No Name of Food:   Vaccinations: DHLP (Distemper -dog) :               Yes   No Boardetella:                                   Yes   No    FVRCP (Infectious Disease -cat):   Yes   No    Rabies:                                          Yes   No    Feline Leukemia (cat):                   Yes   No    Other Vaccines:   Heartworm Test: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2005 2006 2007 Heartworm Prevention: Yes   No Prior Illness: Prior Surgery: Comments