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Canine Patient History

"*" indicates required fields

Client First Name*

Client Last Name*

Patient Name*

What kind of food are you feeding? How much and how often?*

Have you noticed any coughing, sneezing, vomiting or diarrhea?*

Yes

If yes, please explain*

Do you use any heartworm prevention?*

Yes

Do you use any flea/tick prevention?*

Yes

If yes, year-round or seasonal? When was the last dose?*

Do you give any medications or supplements?*

Yes

Do you need any refills on any medications or supplements?*

Yes

If yes, please list all medications and doses*

If yes, which ones?*

Are there any behavioral changes or concerns with your pet?*

Yes

If yes, please explain*

Does your dog have a known history of vaccination reactions?*

Would you prefer your LAB RESULTS via email or text? Please provide an email address or cell-phone number.*

Cell Phone

Email*

Phone*

Are there any other concerns/problems for the doctor to address?*

Yes

If yes, please list*

Signature*

Date*

MM slash DD slash YYYY

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Name

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Our Hospital
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AAHA-Accredited Practice
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Get in touch

207-935-2244

203 Bridgton Road,
Fryeburg, ME 04037

Make an appointment

207-935-2244

203 Bridgton Road,
Fryeburg, ME 04037

Make an Appointment

Online Pharmacy

Home
Our Hospital
Services
AAHA-Accredited Practice
Contact Us

Business Hours

Monday

7:30am - 6:00pm

Tuesday

7:30am - 6:00pm

Wednesday

7:30am - 6:00pm

Thursday

7:30am - 6:00pm

Friday

7:30am - 6:00pm

Saturday

8:00am - 6:00pm

Sunday

Closed

*Closed 12-2 Thursdays