Hillsboro Veterinary Clinic

142 SW Baseline St.

Hillsboro, OR 97123

503-648-4117

Patient and Client

Information Sheet

Thank you for giving Hillsboro Vet Clinic the opportunity to care for your pet. So that we may become better acquainted, please complete the following

Mr.

Mrs. Owner-(s) Spouse

Dr. ^{LAST FIRST LAST FIRST}

Ms.

Children

^{FIRST NAMES} SOCIAL SECURITY NUMBER

Address

^{STREET CITY STATE ZIP CODE PHONE}

What is the best time to reach you at home?

Employer / Address

^Title

Spouse's

Employer / Address

^Title

If necessary, may we call you at work? Yes No, Your spouse? Yes No

^{Phone Number}

How did you become aware of our clinic? Yellow Pages Hospital Sign Other

Personal Recommendation - Whom may we thank?

So that we are able to suit your individual needs, which do you feel most applies to you:

Please Check ONE

(1) I feel that my pet is another member of our family.

(2) I feel that my pet is just a pet.

Please Check ONE

(1) I want the best medical care available for my pet; please recommend anything you feel necessary for good health.

(2) I want good medical care for my pet, but there is a limit to what I am able to have done.

(3) I want you to perform only the service that I request.

Please Check ONE

(1) I want to learn as much as I can about pet health care, please explain in detail what has been done for my pet or what is needed.

(2) I would prefer you just summarize what has been done for my pet or what is needed.

(3) I want my pet healthy, but don't need to know what has been done.

Please Check ONE

(1) I prefer to be present when my pet is examined and treated.

(2) I would rather not see my pet examined or treated.

Would you like us to keep you informed about procedures to lengthen your pet's life? Yes No

How old was your pet when acquired? How long has your pet been with you?

How long would you like your pet to live? How many hours is your pet outside each day?

(over)

What health care or grooming products are you currently using?

Is your pet currently on a special diet or any medication?

List any known drug allergies:

What prior illness or surgery should we know about?

Are any of the following a concern to you in your pet's behavior? Please Check.

Excessive Barking Biting Shedding Straying from Home House Breaking Smell

Problem Around Children Excessive Itching/Scratching Wetting/Spraying in House

Overly Rambunctious/Overly Enthusiastic

Would you be interested in learning how to improve your pet's manners? Yes No

Has your pet been exposed to any new pets recently? Yes No

Pet information (Please fill in the following for each pet)

	Pet 1	Pet 2	Pet 3
Name
Species (Dog, Cat, etc.) Breed
Description
Date of Birth
Sex
Spay or Neutered
Vaccination Dates
DHLP (Dogs)
Parvovirus (Dog)
Corona Virus (Dog)
FVRCP (Cat)
Rabies (Dog and Cat)
Fecal Check (worms)
Dentistry
Feline Leukemia (FeLV) Test
FELV Vaccination
On "Progam"?
On “Advantage or Frontline”?
Diet?

Payment is to be made when the service is performed or when you pick your pet up. We accept cash, personal checks, VISA, MasterCard and Discover. Please indicate your choice of payment method:

Cash Check (Drivers License required) VISA/MC Discover

Client’s Signature

Again, thank you for giving us the opportunity to serve you!