New Patient Questionnaire
Date:
Patient Name:
Client Name:
Thank you for allowing us to be a part of your pet’s healthcare. Our hospital is a fullservice veterinary hospital with a focus on preventative care in addition to general
medicine and surgery. To help us get to know your pet’s health, facilitate your
experience, avoid appointment delays or rescheduling, please complete this form
within 48 hours by email (or fax) of your first appointment (including newly adopted
patients with minimal histories to pets with extensive medical histories). Please fill
out one form for each pet to the contact information below.
Has your pet been to a veterinarian before?
☐ Yes
☐ No (skip to question 2)
If yes, please list the most recent 3 veterinary clinics (at least name, city/state – ideally phone number or email address if
feasible). If the pet was previously listed under another name or individual on the medical chart please note that also.
E.g. Two Rivers Veterinary Hospital, West Fargo, ND 701.356.5588 info@tworiversveterinaryhospital.com
1.
2.
3.
2. Do you consider your pet overall healthy at home? If unsure, please list the top concern(s) you may like us to further
address during the visit. ☐ Yes, no concerns at this time (skip to question 3)
☐ No (please specify concerns below)
1st concern:
2nd:
3rd:
4th:
5th:
What medications is your pet currently taking? *Please bring in with you to your appointment
Vitamins/Minerals
Flea/Tick
(e.g. omega fatty acid, SynoviG4s
glucosamine/chondroitin sulfate, etc)
(e.g. Parastar Plus, Frontline
Plus, K9 Advantix)
Monthly parasite
preventative
(e.g. Sentinel, Heartgard
Plus, Revolution)
Other prescriptions –
include frequency/dose
(e.g. topical shampoos,
Rimadyl, etc)
Any other questions/comments that would benefit our team:
Sincerely,
Tracie Hoggarth, DVM and Teri-Lee James, DVM MPH
Email: lisa@tworiversveterinaryhospital.com
Phone: 701.356.5588
Fax: 701.356.5589