Patient History Form

Title

Medication and Food

Would you like us to prescribe flea and worming treatment for your pet?

Yes
No

Please note included as part of PHC, or 10% off at time of booster or vaccination course

Do you wish to purchase any food at the time of your pet's appointment?

Yes
No

25% off stocked brands, life-stage and prescription for PHC members

If Yes, Please enter the product and quantity (3 months allocation dispensed if due and on PHC)

If Yes, please enter name and bag size

Does your pet require a repeat of any chronic medication(s) or supplements?

Yes
No

20% off selected chronic medications and 10% off supplements/pet shop sales on PHC

If Yes, please enter drug/supplement name, dose, and quantity

Diet History

How active is your pet normally?

Not Very ActiveModerately ActiveVery Active

How Would You Describe Your Pet's Weight?

UnderweightIdeal WeightOverweight

Where does your pet spend most of their time?

IndoorsOutdoorsIndoors & Outdoors

Please list below the brands and products (if applicable) and the amount of ALL foods, treats, snacks, dental hygiene products, rawhides and any other foods (including human ones!) that your pet currently eats, including foods used to administer medications

*If you feed by volume, what size measuring device do you use? *If you feed tinned/canned food, what size tins/cans/trays?

Do you give any dietary supplements to your pet (for example: Vitamins, Glucosamine, Essential Fatty Acids, or any other supplements)?

YesNo

If Yes, please list brands and amounts per day

Additional Questions Relating to Your Pet's Appointment

Is Your Pet Insured?

Yes
No

If yes - please provide policy details including name of insurance provider, policy number, type of cover, mandatory excess and owner percentage contribution amount, claim limit, and details of any exclusions on your pet’s policy.

If this information is unknown, then please check your policy documents, or contact your pet’s insurance provider to enquire. We are unable to offer direct claims for costs incurred, without this information.

Are Any Other Procedures Required? (Please Note Free of Charge if on PHC)

Clip Nails

Yes
No

Empty anal glands

Yes
No

Would you like to join our Pet Health Club?

Yes
No

New Puppy, Kitten, or Bunny?

If you do not have insurance for your pet, would you like us to issue 4-week's free immediate veterinary cover through Petplan?

Yes
No

*Please note, a link will be sent to you via email/SMS and this must be activated within 24 hours of receipt, to receive the maximum free cover available. The cover-note shall be issued following your pet’s appointment with the vet.

When did you get your new arrival?

Have they been Microchipped?

If yes - please enter their microchip number.

Have they received any Vaccinations so far?

YesNoDon't know

If yes - please bring their vaccination card to their first appointment.

Have they received any flea or worming treatment?

If yes - please enter product(s) and date(s) received.

Have you noticed any signs of disease since collecting them from the breeder?

If yes - please provide brief details.

Security Question

Patient History Form

To help us get to know you and your pet better, please answer these questions before your appointment.

About You and Your Pet

Please Tick Appropriate Answer

If Your Pet Is Unwell, Please Complete The Following

Medication and Food

Diet History

Additional Questions Relating to Your Pet's Appointment

Are Any Other Procedures Required? (Please Note Free of Charge if on PHC)

New Puppy, Kitten, or Bunny?