New Patient – Large Animal

Please complete this form either online or download, print & bring to your next visit.

New Patient – Large Animal – Download & Print

Owner*
Date*
Signalment
Registered Name*
Nickname
Sex*
- Gelding
- Stallion
- Mare
- Spayed Mare
Date of Birth*
If unknown - give best approx. date and/or year
Date Gelded/Spayed
If unknown - give best approx. date and/or year
Breed*
Pedigree
Color*
Markings
Weight
Height*
Registration #
Tattoo/Brand
Microchip*
- No
- Yes
Animal's Insurance Information
Name
Relation to client
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
Insurance Company Name
Co. Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Co. Phone
Type of Coverage
Policy #
Group #
Other Information
Use / Occupation / Favorite Activities
Specify current and previous.
Habits / Vices
Singly or Herd Raised*
What is the reason for this visit?*
Medical Information and History
Vaccination History*
Please include the dates, types of vaccines, and any reactions; also titers if taken.
Deworming History*
Please include the dates, chemical used, and any reactions.
Dentistry*
Please include dates, frequency of care, and any abnormalities.
Farriery*
please include dates, frequency of care, any abnormalities, past or present
Describe what your animal eats and drinks, and any changes in the last six months*
(brand, amount and frequency of feed, type of feed tubs & buckets, how hay is fed, water source.
Any medications or supplements?*
List substances, brands, and dosages (past and present.)
Describe where and how your animal lives, exercises, and sleeps.
Include stall floor/bedding, turnout facilities & schedule, arena footing.
If your horse is boarded, please give name, address, and phone number of stable and caretaker.
Type of halters, cribbing collars, shanks
Blankets, boots
include make, model, size, when used
Saddles, bridles, bits
include make, model, size, repairs
Training and Competition History
type, duration, any significant occurrences - positive or negative
Briefly describe your animal's personality and disposition, position in herd pecking order
note any changes and when they occured
Injuries
Please list approximate dates, including falls, lamenesses, wounds, head trauma, fractures, surgery, surgical implants or orthopedic hardware
Ilnesses
Please list approximate dates,(including GI upset, respiratory disease, cancer, allergy, thyroid disease, hormonal dysfunction, urinary problems, heart disease, infections
Emotional Disturbances
Please list approximate dates, (behavioral problems, fears, phobias, aggression, emotional trauma.
Training Problems
including stiffness, asymmetries, gating abnormalities, biting problems.
Diagnostic Information
Does your animal have previous blood work?
If significant, please arrange for us to have a fax or copy of bloodwork for our records.
Does your animal have previous radiographs?
If so, owner must request that they be sent to us.
Other
Additional observations or concerns
Please include anything that comes to mind, whether you think it is significant or not.
Other Veterinarian
Name Hospital Name Address Phone Fax
Other Veterinarian
Name Hospital Name Address Phone Fax
Other Therapists
Name Hospital Name Address Phone Fax
Other Therapists
Name Hospital Name Address Phone Fax
Farrier
Name Address Phone Fax
Dentist
Name Address Phone Fax
Alerts - Current or Previous
- Bites
- Strikes
- Difficulty Loading or Unloading
- Difficulty Standing or Shoeing
- Pulls Back
- Difficulty Traveling (i.e. - tranquilized for shipping)
- Kicks
- Rears
Small Animal / Horse / Human Aggressive:
List all that apply
Hormone Implant
provide medication and date
Allergies
Medications
Supplements
Foods
Bedding
Fly Spray
ATTENTION: Please DO NOT apply Show Sheen or hoof oil to your horse before coming to your scheduled appointment. Cancellation fee will apply if not given 24 hours notice (Lg./ $100, Sm./ $25.)

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New Patient – Large Animal

Signalment

Animal's Insurance Information

Other Information

Medical Information and History

Diagnostic Information

Other

Alerts - Current or Previous

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Name	Hospital Name	Address	Phone	Fax

Name	Hospital Name	Address	Phone	Fax

Name	Hospital Name	Address	Phone	Fax

Name	Hospital Name	Address	Phone	Fax

Signalment

Animal's Insurance Information

Other Information

Medical Information and History

Diagnostic Information

Other

Alerts - Current or Previous

This site uses tracking technologies

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