Comments or questions are welcome. * indicates required field Name:* Street Address:* City, state, zip:* Home phone Mobile Phone: Email:* How may be best contact you? home phone mobile e-mail Place of Employment: Work Phone: May we contact you at work? yes no How did you hear about Bern-Sabetha Veterinary Clinic? friend or relative yellow pages chamber of commerce newspaper ad Facebook Internet search If a friend, yellow pages directory or other, please specify Is there anybody else who is authorized to make decisions regarding your pet? yes no If yes, name: How may we contact them? Please list an Emergency Contact if we are unable to reach you: How do you view your pet(s)? Like a family member, I am concerned about all health issues. Simply as a pet, not as concerned about all health issues. Will you be providing medical records or would you like us to request a copy of your pet’s medical records from your previous veterinarian? I will provide Please call No Previous Veterinarian: Pet Information - Pet Name: Species Dog Cat Other If other Species please specify: Breed: Sex: Male Female Date of Birth: Neutered/Spayed? Yes No Microchipped? Do you have any other pets in your home? if yes, please list names and species Does your pet have any prior illnesses or injuries we should know about? If yes, please describe Have you medicated your pet recently? (including over the counter drugs) If yes, please state medications Where did you get your pet? How long have you owned your pet? On average, how many hours a day is your pet outside? How often do you bathe your pet? What brand food does your pet eat? Where does your pet sleep? Select All Statements that Apply: Pet goes to a groomer Pet boards your pet at certain times of the year Pet has allergies Pet spends long periods of time alone Pet is used for hunting or sporting You plan to breed your pet Pet gets table food Pet has ever had dental care You travel with your pet Pet is on a flea and tick prevention program Pet is on an intestinal worm preventative Pet is on a heartworm preventative pill Pet has ever had a urine analysis Select All Symptoms that are a Problem: Bad Breath Coughing/Sneezing Vomiting Diarrhea/Loose Stools Ear Infections Housetraining/Litterbox Itching/Scratching too much Straying from home Biting Odor Difficulty getting up Excessive water consumption Limping Overweight Painful Any Other Symptoms: Please list any other concerns or questions you may have that we can answer for you: CAPTCHA Code:* DOWNLOADABLE PDF FORM The Welcome Form is also available as a downloadable pdf to print, fill out and bring with you.