Client Information

Client Name*

Email*

How did you find out about our practice?*

Clinic Location
Personal Reference
Internet Search / Website
Clinic Sign
Newspaper / Print Media
Social Media
Other

Please use this area to give us any other important information about yourself or your family.

Patient Information

Patient Name*

Where did you obtain your pet?*

Breeder
Shelter / Rescue
Friend / Family
Website (Kijiji, Facebook, etc.)
Other

How long have you owned your pet?*

Medical History

Does your pet have any known medical conditions?*

Allergies, chronic illness, etc.

Is your pet is on any medication or monthly flea, tick, and heartworm prevention? What type of medication or prevention? What is the dose and frequency your pet is currently receiving? Do you need any refills for your medication(s)?*

(For cats) Is your cat indoors only or indoor/outdoor? Do they have contact with wildlife or other outdoor pets?*

(For dogs) Does your dog go to the dog park, groomer or a boarding facility or have social time with dogs from other households?*

(For dogs) Does your dog tend to drink from an outdoor water source (ponds/puddles) or have access to wildlife areas or nature trails?*

What diet does your pet eat, how much and how often? Please include any treats, supplements and human food.*

Does you pet have any known food allergies or sensitivities?*

Has your pet undergone any surgeries? Please provide details and dates.*

How does you pet interact with other animals? How do they behave around strangers?*

Has you pet experienced any stress or anxiety when visiting the vet? Our staff have been trained in Fear Free techniques and we have ways to help.*

Does your pet require calming medication for their visit? If you require medication, please contact the clinic at least 24 hours prior to your appointment for a refill.*

Have there been any behaviour changes which you have noticed?*

Do you have any recent health concerns for your pet?*

Have there been any recent changes in appetite or thirst?*

Have there been any changes with your pet's urination or stools?*

Any coughing or sneezing?*

Any vomiting or diarrhea?*

Any new lumps or bumps?*

Any lameness or mobility concerns?*

Are there any additional procedures you would like to request with your appointment?*

Will you be traveling to the United States within the next year?*

YES
NO

Social Media Consent: Do you give Ilderton Pet Hospital permission to take photos of your pet, identify them by name, and share them on our official Facebook and Instagram pages?

YES
NO

***Parasites can pose a human health risk. We recommend bringing a fresh (within 24 hours) fecal sample to check for internal parasites every year or more frequently if there are any digestive concerns or high risk for parasite exposure. ***

We thank you for taking the time to fill out this form and we look forward to seeing you and your companion soon.

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New Client / New Patient Questionnaire

Client Information

Patient Information

Medical History

Mailing Address

Office Hours

Monday	8:30am – 5:00pm
Tuesday	8:30am – 5:00pm
Wednesday	8:30am – 5:00pm
Thursday	8:30am – 5:00pm
Friday	8:30am – 5:00pm
Saturday	8:30am – 12:00pm
Sunday	Closed