Home |Timbercreek Animal Hospital
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Suite 100    2754 Hwy 276   Rockwall, TX  75032
Phone:        972-722-1644

Name: __________________ Birth date/Age: ______________ Breed:______________

Sex: _______________ Spayed/Neutered: ____________ Color: ___________________

How long have you owned this pet: ______________ What type of food/diet do you feed your pet: _________________ Is your pet on a special food/diet? ___________________

Has your pet had any previous surgeries or illness? ______________________________

Does your pet have allergies to vaccinations or any medications?  (yes/no): ___________ (if yes, type): ____________________________________________________________

Does your pet have flea allergies? (yes/no): ____________________________________

Is your pet on flea preventative? (yes/no): ________ (brand): ______________________

Is your pet on any other medications? _________________________________________

Does your pet have a microchip? (yes/no): _____ (if yes, registration#): _________________
If answer is no to the above question, are you interested in hearing about or having a microchip inserted in your pet for permanent ID? (yes/no): _________________________  

Date of last fecal:___________ Date of last FeLV/FIV combo test:__________________
Date of last blood test:____________  Date of last rabies vaccination:________________
Date of last FVRCP vaccination:__________________

Is your pet indoors, outdoors, or both?_________________________________________

What is the name of your previous veterinarian or hospital?________________________

What is your pet's temperament while in the hospital?____________________________

What is the reason for your visit to our hospital today?____________________________