MANCHACA VILLAGE VET CLINIC
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ADDITIONAL PETS FORM
Date: 
Owner's Name:
Contact Phone Number:
Do you have an appointment?
Yes
No
If yes, please enter the date of your appointment. 
Pet's Name:
Pet's Sex:
Male
Female
Pet's Age
Pet's Breed:
Pet's Color:
Type of pet:
Chronic Ailments (diabetes, seizures, etc.)
Yes
No
List Ailments:
Have you medicated your pet recently (including over the counter drugs)?
Yes
No
If yes, state medications:
Date Of Most Recent Vaccinations: 
Has your pet been tested for heartworms?
Yes
No
If yes, when: 
Any prior illness or injury we should know about?
Yes
No
If yes, what and when?
Do you have your pet groomed?
Yes
No
Do you have your pet boarded at times?
Yes
No
May we inform you of longevity issues such as regular dental care and special diets?
Yes
No
Do you use your pet for hunting, sporting or camping?
Yes
No
On average, how many hours a week is your pet outdoors?
Other pets (dog, cat or other ) in the household?
Yes
No
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