KITTANNING VETERINARY HOSPITAL
170 East Brady Road - Rt. 268 / Kittanning, PA 16201 /Phone (724) 543-2814
Veterinarians:
Robert L. Lash, V.M.D. Gabriel Durkac, D.V.M. Mark W. Beere, V.M.D.
David F. Meleason, D.V.M., Israel P. Isenberg, D.V.M.,
Jon Jenkins, D.V.M. and Anusha Natarajan, D.V.M.
“A Healthy Pet is a Happy Pet”
Please bring this completed form and any prior vaccination
records with you on the date of your pet’s appointment.
Thank you for giving us the opportunity to care for your pet(s). So that we may become better
acquainted, please complete the following:
CLIENT INFORMATION
Date
Spouse’s name
Name
Address
City
______
______
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_______________________
Home phone
State ______
___
______
Zip_______________________
____________ Cell phone
Work phone
_
________________
Alternate/spouse phone
_
______
Email Address _________________________________(Addresses will not be sold or shared)
In addition to our website, we have a link to your own personal Pet Portal. This site is a secure,
private pet health website that gives you direct access to manage your pet’s health 24/7. We’re
happy to provide Pet Portals free of charge to all clients who have an active email address.
How did you hear about us?
____ Yellow Pages
_____ Internet
_____Hospital Sign
____ Veterinary Practice
Veterinary Practice Name ___________________________
____ Client
Client whom we may thank __________________________
____ Other ____________________________________________
Please turn form over and continue to supply us with information to better serve you.
Client Name ____________________________________________
Client No_________
PATIENT INFORMATION
Pet #1
Pet #2
Pet #3
Name
Date of Birth
Male or Female
Color
Breed
Spayed or Neutered
Brand of food ________________
Canned/Dry/Both
Treats given - Yes/No
Does the pet frequent a boarding kennel, grooming salon, attend Day Care, or socialize with other
pets? YES NO
Any additional information you would like to share with the doctor at this time:
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Payment is due in full at the time services and products are rendered