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Owner's Name
Today's Date
Phone
Email
Pet's Name
What breed is your dog?
How old is your dog? (provide DoB if possible)
Sex
Male
Female
Is your pet spayed / neutered?
Yes
No
Previous Veterinarian
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FEEDING
What does your dog eat? (Please be specific primary diet, vitamin supplements, and treats.)
How much do you feed your dog? Please specify in cups, or ounces.
How often do you feed your dog?
Once
a
day
Twice
a
day
Free-Feed
/
Continuous
Other
Please describe
How often is water changed?
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MEDICAL ISSUES
Please list any past or current health problems:
What medication(s) is your dog currently taking? Please include any over the counter medications.
Is your dog on flea and heartworm prevention?
Yes
No
What kind?
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