Dog Medical History - Erlanger Veterinary Hospital

Name *

First

Last

Today's Date

Appointment Date and Time (if already scheduled)

Date

Time

Pet Do Has

Email *

Phone

Address

Address Line 1

City

State

Zip Code

Pet's Name *

Pet's Age *

Pet's Breed *

Pet's Sex *

Upload a photo of your dog

Drag & Drop Files, Choose Files to Upload

Reason for today's visit?

Have you been to our satellite office, Union Pet Hospital, recently?

Yes
No

Are you interested in Pet Insurance?

Yes
No

Does your pet travel out of state?

Yes
No

If yes, where?

Do you board or groom your pet?

Yes
No

Do you brush your pet’s teeth?

Yes
No

What is your pet’s diet? Please specify brand & amount.

Has your pet shown any of the following signs or symptoms? If yes, please check all that apply

Has your pet shown significant change in any of the following?

Character of bowel movements?

Yes
No

Appetite?

Yes
No

Frequency or amount of urination?

Yes
No

Drinking?

Yes
No

Weight gain or loss?

Yes
No

Behavior?

Yes
No

Do we have your permission to post any photos or videos on our hospital website, training guides, and/or Facebook, TikTok or Instagram? *

Yes, you have permission.
No, you do not have permission.

*

What is 6+6?