Client Name (first & last)
Spouse/Partner (first & last)
Address
City
State
Zip
Home Phone
Mobile
Work
Email
Agent/Co-Owner Name
Who may we thank for referring you today?
Pet's Name
DOB/Age
Breed
Color
Please select the appropriate option
Is your pet up to date on rabies vaccination?
Doctor's Name
Clinic/Hospital Name
Briefly, please describe the reason for today’s visit.
Please describe any diseases/ conditions that your pet currently has or has had in the past.
Please list any medications your pet is currently taking. This includes vitamins, supplements.
Does your pet have allergies to medications, anesthetics, or foods? If yes, please provide details in the space provided.
Signature of Owner/Agent
Date
You and your doctor will be provided with a report from the doctor for every examination performed on your pet at Tufts VETS. Thank you for trusting us with your pet!