Bardstown Veterinary Clinic
Please take a moment to answer the questions below to help us provide better service to you and your pet.
Name:_____________________________ Address:_____________________________________________
Home:_________________ Cell: _________________ E-mail:____________________________________
What is the best way to contact you? Home
Cell
Text
E-mail
Now please tell us about your pet……
My pet spends most of his/her time: ( ) Indoors ( ) Outdoors ( ) In and Out
My pet comes in contact with other pets:
( ) While boarded at a kennel
( ) While being professionally groomed
( ) While Bathed
( ) While at a dog park
( ) My pet is never around other pets
What do you feed your pet?_______________________________________________________________
If you offer table food, list examples.________________________________________________________
Is your pet on flea and tick preventatives? If so, what kind?_____________________________________
Is your pet currently on Heartworm Preventatives? If so, what kind?____________________________
Is your pet receiving any medications other than ones dispensed from this clinic? If so, please
list.____________________________________________________________________________________
Which best describes your pet’s weight: ( ) Too thin ( ) Normal Weight
( ) Gained a few pounds ( ) Needs to lose weight
Which best describes your pet’s breath? ( ) Not bad ( ) Unpleasant ( ) Really Bad
Which best describes your pet’s water consumption? ( ) Same as last year ( ) More than last year
Please check any of the conditions that your pet has experienced: ( ) Crying ( ) Eye Discharge
( ) Hair Loss ( ) Skin Growth ( ) Sneezing ( ) Change in Appetite ( ) Change in Behavior
( ) Vision Problems ( ) Fleas or Ticks ( ) Change in Weight ( ) Frequent Urination ( ) Increased Thirst
Do you need a refill of any medications? _____________________________________________________
Bardstown Veterinary Clinic and its employees have the right to take photographs and/or videos of me
and my pet to use in social media websites. These will be published with or without use of mine or my
pets name for any lawful purpose based on my wishes when the photo is taken. _____Yes ____No
Please note any questions or topics you would like to discuss.____________________________________
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