New Patients Form - Welcome To Mill Creek Animal Clinic

Thank you for giving us the opportunity to care for your pet. We will be happy to answer any questions you have about your pet’s health.

Name of Pet:
Reason for Visit:
Type of Pet:	Dog Cat Other
Other:
Breed:
Color:
Birthdate (or Age):
Microchip:	yes no
(if yes) Microchip #: (we can scan your pet)
Gender:
Vaccinations:
Has your pet been vaccinated within the last 12 months?:	Yes No
Dates Vaccinated?: (We can call your previous veterinarian for these dates)
Rabies vaccination is required by law. Please inform us if your pet’s vaccinations are current and the dates they are due so that we may update your pet’s vaccination history.
Heartworm Disease:
Heartworms are a serious threat in our area. Has your dog been tested for heartworm disease within the last 12 months?:	Yes No
Is your dog currently on heartworm prevention year ‘round?	Yes No
Please tell us when your dog’s heartworm test is due and if any heartworm prevention as well as flea control is needed. Date Due:
Feline Leukemia (FeLV) / Feline Immunodeficiency Virus (FIV) AIDS:
These viruses can devastate your cat’s immune system and can impair healing. We recommend that all cats be tested for FeLV and FIV. Tested?	Yes No
Date:
Prior injuries or surgery:
Current medications:
Any known drug or vaccination allergies?	Yes No
To what? (If known):
Known season allergies? (Please list the time of year, if possible)
Present Diet?

All fees are payable at the time of treatment or release of your pet.
Owner Name:
Date: