Owner Name*

First Last

Pet's Name*

Have you owned your pet since he/she was a puppy/kitten?*

If no, age of your pet when obtained:

Is your pet current on vaccines?*

Date of last Rabies vaccine:*

Did you vaccinate your pet for leptospirosis?*

Date of last leptospirosis vaccine:*

Has your pet traveled outside of Phoenix in the last few years?*

If yes, where?*

Has your pet had any of the following? Please check all that apply:*

Other

What is your pet's current diet?*

Do you feed your pet a grain free diet?*

How often/how much do you feed your pet?*

Do you feed your pet a raw diet?*

Is your pet on any medications/supplements?*

If yes, please note the medication name/strength, frequency (once daily, etc.), and time of last dose given:*

Please include any over the counter medications.

Please include any other information you think will be helpful for the attending veterinarian:

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Health History Form