Multi-Pet Patient History Form

Brown Veterinary Housecalls

Dover
Mesa, AZ 85205

(480)494-6034

www.brownvetservices.com

Additional Pet Form

If a New Client request form has been submitted and a multi-pet appointment is requested, please submit this form for each additional pet

This form may also be used for Active Clients with a new pet to household

Thank you

Note: This is not the same as the new client form

Patient History Form

Correct Form Confirmation (required)

I have not submitted any forms and would like to become a new client-please stop, this is not the correct form. Please click link above for new client form
I have submitted the new client form and am submitting this form because I requested a multipet appointment or wish to add additional pets to my records-please continue
I am an active client with a new pet to become a new patient-please continue

*(required)*

First Name (required)	Last Name (required)

Email address (required)

Patient Name (required)

Breed, Sex, Age and Color (required)

Type of Appointment Requested (required)

Housecall Wellness & Prevention General Medicine
Housecall Sick, Injured, Nonemergency General Medicine
Housecall TCVM Acupuncture
Housecall TCVM Acupuncture & Chinese Herbal Medicine
Housecall TCVM Acupuncture, Herbal Medicine & Food Therapy
Housecall-Integrative Medicine (General and TCVM)
Quality of Life Assessment General Medicine
In Home Euthanasia & Cremation
Soul Puppy Holistic Healing Mesa TCVM Acupuncture office
Equine Mobile Acupuncture

Reason for appointment/main concerns (required)

Duration of above concern(s) or condition(s)

Goal of treatment

Diet and frequency of meals

Medications-please list all including strength and frequency of dosing

Supplements or Herbs

Is your pet on heartworm prevention? :

Is your pet on flea or tick prevention

Yes
No

Please list type of heartworm or flea and tick prevention

Is your dog, cat or horse current on vaccines

Yes
No
Unsure

Does your pet have a history of vaccine reactions?

Yes
No
Has never had vaccines

If your pet has had a previous vaccine reaction, please list which vaccine i.e. distemper/parvo, rabies, etc

Has your pet had a full blood panel in the past 12 months?

Yes
No
Unsure

Does your pet have a history of Valley Fever?

Yes
No
Never been tested

Please list any history of chronic conditions i.e. abnormal blood work, renal or liver disease, heart murmur, seizures, colic, laminitis, navicular, etc.

Please list any previous surgery or dental cleanings/teeth floating along with approximate year or age of procedure

Has your dog, cat or horse ever had acupuncture?

Yes
No

Has your dog, cat or horse ever had chiropractic treatments?

Yes
No

Temperament Disclosure: Please tell us how you pet does at the veterinary office? (Anxiety, aggression, muzzle, nervous, happy, oral or injectable sedation, etc)

Temperament and Handling Information (required)

Horses only: Please list date and type of last dewormer and fecal egg count

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