Client & Medical History Update

Client Name *

First

Last

Primary Phone *

Secondary Phone

Email *

*PetDesk is our new app to send appointment reminders, pet updates and lab results for your pet via text or email. Email is required to upload your pets’ data into the app.
*However, you can OPT-OUT of emails after you register.

Patient Name *

Species *

Cat
Dog

Do you have a new address? *

Yes
No

Address *

Address Line 1

Address Line 2

City

State

Zip Code

County

Boone
Winnebago
Other

If other, please specify:

Any change in ownership of any pet(s) in the last 18 months? (i.e. divorce, moved, re-homed pet, lost pet) *

Yes
No

Please elaborate. *

Last Preventative Purchases

Date of last Heartgard purchase

If unknown, please leave blank

Amount purchased

Needed?

Yes

Date of last Nexgard purchase

If unknown, please leave blank

Amount purchased

Needed?

Yes

Date of last Frontline purchase?

If unknown, please leave blank

Amount purchased

Needed?

Yes

Date of last ProHeart purchase?

If unknown, please leave blank

Amount purchased

Needed?

Yes

Was your last preventative purchase one not listed above?

Yes
No

If yes, please specify what preventative it was.

Date of last purchase?

If unknown, please leave blank

Amount purchased

Needed?

Yes

Where do you purchase your preventatives?

Perryville Pet Hospital
Online Pharmacy
Local Pharmacy
Other

Please specify.

Any medication refills needed? *

Yes
No

Please specify.

Please select one. *

I give Perryville Pet Hospital permission to include photos of, or references to my pet(s), on ourwebsite or any social media (your personal information will never be shared).
No I do not give permission.

Cats Only

Does your cat go outside?

Yes
No

If indoors, are they exposed to any cats that go outside?

Yes
No

Do you have a multi-cat household? (≥ 3 cats)

Yes
No

Are you using flea control?

Yes
No

What flea control are you using?

Dogs Only

Does your dog go to dog parks/Forest preserves?

Yes
No

Do you use boarding and/or grooming facility?

Yes
No

Do you give a heartworm preventative?

Yes
No

What frequency?

Seasonally
Monthly
Year Round
Other

My pet is on:

Heartgard
ProHeart
Other

If Other, please specify.

When was the last dose given?

Within 30 days
≥30 days
≥90 days

Would you be interested in one heartworm dose that lasts 12 months?

Yes
No

Do you use flea/tick preventative?

Yes
No

What frequency?

Seasonally
Monthly
Year Round
Other

If Other, please explain.

Would you be interested in one dose that lasts 12 months?

Yes
No

Think of your pet’s health the last few months

Please select any that have been affecting your pet over the last few months. (Select all that apply)

Which leg(s)?

Is the itching happening daily, weekly? Any visible skin problems? Are they licking as well?

Please describe your other concerns.

Does your pet ever show (select all that apply)

Anxiety
Fear
Aggression

Where does this happen?

If Other, please explain.

Is your pet on any medications, vitamins, or supplements?

Yes
No

What meds, vitamins or supps?

What food do you currently feed your pet? How much per day?

What type of treats? How much per day?

Welcome back to Perryville Pet Hospital!

Please update your Client and Pet information below. You can either fill out the form online and submit or download, print and email to [email protected].

Last Preventative Purchases

Cats Only

Dogs Only

Think of your pet’s health the last few months

Ready to Visit?

Questions?

Contact Us

Location

Contact Information

Hours

After regular business hours and on holidays, Guardian Vets is here!

Emergency Information