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					Stonewall Veterinary Clinic 7627 Heritage Village Plaza Gainesville Virginia 20155 703-754-9888

PET INFORMATION
Pet’s Name _______________ Sex: Female/Spayed Male/Neutered Unsure Date of Birth _________ Canine/Feline/Other __________ Breed ____________________________ Color ____________________ Where were most recent vaccines given: __________________________ Date _____________________ Is your pet: Indoor only/Outdoor only/Both? What type of flea and/or tick prevention: __________ Is you pet currently on heartworm prevention? Y / N What type? Interceptor/Sentinel/Heartgard Has your cat been tested for Feline Leukemia? Y / N Does your pet have a tattoo or microchip? Y / N Feline Aids? Y / N Any Positive Results?____

If yes, which and ID number _________________

Any known medical problems or allergies? ____________________________________________________ Does your pet have any idiosyncrasies we need to know? i.e., bites, scratches, fear of white coats, responds to more/less restraint, more calm with or without owner?

PET INFORMATION (additional pets)
Pet’s Name _______________ Sex: Female/Spayed Male/Neutered Unsure Date of Birth _________ Canine/Feline/Other __________ Breed ____________________________ Color ____________________ Where were most recent vaccines given: __________________________ Date _____________________ Is your pet: Indoor only/outdoor only/Both? What type of flea and/or tick prevention: __________ Is you pet currently on heartworm prevention? Y / N What type? Interceptor/Sentinel/Heartgard Has your cat been tested for Feline Leukemia? Y / N Does your pet have a tattoo or microchip? Y / N Feline Aids? Y / N Any Positive Results?____

If yes, which and ID number _________________

Any known medical problems or allergies? ____________________________________________________ Does your pet have any idiosyncrasies we need to know? i.e., bites, scratches, fear of white coats, responds better to more/less restraint, more calm with or without owner?


				
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