New Client Health History

Date:

File #

The staff of Louetta Veterinary Medical Center thanks you for the opportunity to provide veterinary care for your pet family members. Please take a few moments to fill out this form as completely as possible.

CLIENT INFORMATION

Last Name:

First Name:

Street:

city:
State:
Zip:

Phones: Home#:

Work#:

Cell #:

SPOUSE / CONTACT #2 INFORMATION

Name:

Relationship:

Work #:

Cell #:

We send your pet’s reminders by email which will also allow you to access your pet’s health information through pet portals. If you are unable to access email, please alert our staff.

Email Address:

PET’S INFORMATION

Name	Species	Birthday	Age	Breed	Color	Sex
			Y
			Y
			Y

Pertinent Pet Questions Pet’s last annual vaccinations?

Date:

Location:

Pet’s eating habits.What kind of food?:

How Often :

What quantity of food?:

What time:

Is your pet currently on HEARTWORM PREVENTATIVE:

FLEA PREVENTATIVE:

Is your pet on any other medication?

What was the reason you chose Louetta Veterinary Medical Center of Spring:

Location/Drive by

Phone Book (Which one?)

Ad (where?)

Referred by:

I authorize Louetta Veterinary Medical Center of Spring to release information concerning mypet(s) vaccination dates and annuallab results (heartworm & fecal parasite tests) to kennels, groomers, and other veterinary clinics. I understand that this is done as a convenience tome and that this is the only information that will be released without written consent at the time of the request

Signature:

Date: