Primary Owner Information
Name
(Required)
First
Last
Email
(Required)
Pet Information
Pet Name
(Required)
Birth Date (if known)
MM slash DD slash YYYY
Age (if known)
Species
(Required)
Cat
Dog
Other
Breed
(Required)
Color
(Required)
Sex
(Required)
Male
Female
Is spayed/neutered?
(Required)
Yes
No
Unsure
Is your pet current on rabies vaccination?
(Required)
Yes
No
Unsure
Has your pet received regular care at any other veterinary hospital in the past 5 years?
(Required)
Yes
No
Please select all veterinary hospitals where your pet has received care in the past 5 years
Bangor Veterinary Associates
Central Animal Hospital, Onalaska
Hillside Animal Hospital, La Crosse
La Crescent Animal Care
Morganside Veterinary Clinic, Sparta
Sparta Small Animal Veterinary Clinic
Thompson Animal Medical Center, La Crosse
Tomah Veterinary Clinic
Van Loon Animal Hospital, Holmen
VCA Sand Lake Animal Hospital, Onalaska
West Sakem Veterinary Ckuni
Other
Date of last exam (if known)
MM slash DD slash YYYY
Does your pet have a special identification (tattoo, microchip, etc.)?
(Required)
Yes
No
Please list special identification(s) (include microchip number, if known)
Is you pet on any medication(s) or supplement(s)?
(Required)
Yes
No
Please list all medications(s) and/or supplements(s) (including flea/tick and heartworm preventives).
Exactly what does your pet eat, how much, and when (include brand name if known)?
(Required)
Does your pet have allergies or drug reactions?
(Required)
Yes
No
Please list allergies or drug reactions.
Are there any current or past medical conditions of which we should be aware?
(Required)
Yes
No
Please explain the medical condition(s).
As a Fear Free Certified Professional team, we want to make your pet’s veterinary experience is as enjoyable and stress free as possible. As such, it’s important for us to understand what your pet might find upsetting. The following information will help us to adjust our care to better serve and comfort your pet. Please answer the following questions to the best of your ability so we can take into consideration both your & your pet’s preferences.
How and where does your pet travel in the car? (carrier, seatbelt, loose, etc.)
(Required)
During travel to the veterinary hospital, does your pet do any of the following? Select all that apply.
Eager and excited
Reluctant
Hide
Vomit
Drool
Urine/BM
Subdued
Bark/Meow
Whine
Pant
Tremble
Pace
Other
Other
Check any situations listed below that your pet has shown avoidance or dislike of in the past.
Getting in the carrier or the car
Going into the exam room
Entering the vetrinary hospital
Being put up on the table for examination
Other pets and/or people passing by while in reception/check-in
Being taken out of the exam room for procedures
Waiting with other people and animals in the waiting area
Loud voices during examination
Being approached by veterinary staff
Having a rectal temperature taken
Hearing the doorbell, overhead intercoms, or phones ringing
The use of instruments to listen to the heart/lungs or look into the ears
Sounds coming from the back areas of the practice
Other
Other
How would you describe your pet around other animals and people?
(Required)
Does your pet have any sensitive areas that s/he does not like to have touched by you or others?
(Required)
Yes
No
Please explain the medical condition(s).
Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do (nail trims, weight, temperature, ear exam, blood draw)?
(Required)
Yes
No
What are your pet’s favorite treats? (Please bring some to your next visit to our hospital)
(Required)
Does your pet like to play with toys?
(Required)
Yes
No
What kinds of toys?
Has your pet ever been prescribed medications to take before arriving to the veterinary clinic (e.g, sedatives)?
(Required)
Yes
No
Please list the medication(s) and how effective they were.
Please use the following box to give us any other relevant information about your pet (e.g., treat motivated, urinates when afraid, aggressive towards other pets, likes tummy rubbed, etc.)
Please upload your pet's veterinary medical records here (if available).
Max. file size: 8 MB.