Pet Owner's Name * Address * City * State * Zipcode * Preferred Gender Pronoun* Occupation * Email * Preferred Phone * Additional Phone Partner or Co-owner's Name Partner Phone How did you hear about us? ---Friend or FamilyInternetYellow PagesDrive / WalkOther If other... Referred by? (We would like to thank them!)
Pet's Name * Birthdate Species * ---CatDog Breed Color Sex ---MaleFemale Is he or she spayed or neutered? ---YesNoI'm not sure If so... when? Does your pet have any medical conditions (allergies, heart disease, etc)? Please list below: Is your pet on any current medications? Please list below: What is the name of your previous clinic? Please have your pet's previous records faxed or emailed over a few days prior to your appointment, so our doctors have a chance to review. You can also attach them below. Fax: 612-872-7813 | Email: info@lyndaleanimalhospital.com
Has your cat had the following vaccines?
Rabies ---YesNoI'm not sure Feline Distemper ---YesNoI'm not sure Feline Leukemia ---YesNoI'm not sure Has your cat had a Feline Leukemia and FIV test? ---YesNoI'm not sure Does your cat go outside? ---YesNo
Has your dog had the following vaccines?
Rabies ---YesNoI'm not sure Canine distemper/Parvo ---YesNoI'm not sure Bordetella ---YesNoI'm not sure Lyme ---YesNoI'm not sure Leptospirosis ---YesNoI'm not sure
What type of food does your pet eat? Canned or dry? ---CannedDry
Is your pet currently receiving Heartworm preventative? ---YesNo Is your pet currently receiving a flea and tick preventative? ---YesNo
Do you or does anyone in your home have a peanut allergy? (We use peanut butter to help distract dogs during exams.) No,Yes
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Sometimes we like to share about our patients online! This will only be done with your consent, and will always be discussed with you beforehand. Do you consent to having your pet photographed and posted on the Lyndale Animal Hospital Facebook and/or Instagram account(s)?
Yes, I consent to having my pet photographed and posted to the Lyndale Animal Hospital Facebook and/or Instagram account(s)
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