Thank you for entrusting your pet’s care to us today! The following information will be used to help our veterinary team accurately complete your pet’s medical history for today’s visit.

Client Name *

First

Last

Primary Number for Text Reminders *

Primary Email for Notifications *

What heartworm, flea, and or tick preventive are you using? *

If other, please specify *

Have you seen fleas on your pet?

Yes
No

Have you seen ticks on your pet?

Yes
No

Do you have other cats or dogs? *

Yes
No

If yes, how many?

Are all dogs and cats currently vaccinated and on heartworm and flea preventive? *

Yes
No

Type if your pet does any of the following:

How much time does your pet spend outdoors? *

What do you feed your pet? *

Dry
Canned
Both

How much? *

How often *

Any changes in Appetite? *

No Change
Increased
Decreased

Have you noticed any lumps or bumps? *

Yes
No

Any changes in water consumption? *

No Change
Increased
Decreased

Is your pet on any medications? *

Yes
No

Any odor on the Breath? *

Yes
No

Any Home dental care used? *

Yes
No

Check if you have noticed any of the following: *

Is your pet microchipped? *

Yes
No

Would you like more information on a microchip? *

Yes
No

Any Vaccine Reaction History? *

Yes
None

If yes, what happened?

Would you like us to trim the nails today? *

Yes
No

Owners other concerns or questions

Would you allow VANCREST to use photos of your pet for advertising, promotions, or social media? *

Yes
No

Signature *

Clear Signature

Yearly History Ages 1-6 Form

Yearly History Ages 1-6 Form

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vancrest@vancrestonline.com

803-794-6550

1817 Augusta Rd, West Columbia, SC 29169

Monday, Wednesday, and Friday 7:30-1 PM and 2 pm to 6 pm

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