GP & Surgery - New Patient Form - Oxford Veterinary Hospital

First and Last Name:*

Spouse / Co-Owner:

Street Address :*

City , State, Zip Code :*

Primary Contact Name & Telephone:*

Secondary Contact Name & Telephone:

Email:*

How would you like us to contact you?*

Select All
Text
Phone call
Email

If this is an urgent need, please call us to contact! Otherwise we will reach out to you within one business day to schedule the appointment.

Patient information

Pet Name:*

Species:*

Dog
Cat
Other

Breed:*

Color:

Birthdate or age:*

Sex:*

Male
Male Neutered
Female
Female Spayed

Does your pet share their home with other pets? What species and how many? Are any of them also unwell?

Patient history

If your pet is a cat, is your cat:

Indoors only
indoors and outdoors (without supervision)
outdoors only
indoors and outdoors (but only with supervision or in a catio)

Date and type of most recent vaccinations:

What is the Primary Reason for your pet's visit?*

If your pet is experiencing any of the following symptoms, please check all that apply:

If you checked any of the symptoms above, please provide more detail (how long, frequency, etc).:

If your pet is experiencing any of the following symptoms, please check all that apply:

Shaking head or Ear odor
Scooting rear
Hair Loss
Rash
Itching or Scratching
Lumps or Bumps
Unusual Discharge

If you checked any of the symptoms above, please provide more detail (how long, frequency, location, etc).:

Please list all medications your pet is currently receiving. Please include all prescription, preventatives (flea/tick/heartworm), and over the counter medications:

Please list the drug name, concentration of tablet/suspension, and how much and how often they are receiving the med. (ex: amlodipine 2.5mg tab - one tab once daily)

What is your pet's current diet? Brand and type of food? Amount of treats given a day?:

Prior history at other veterinary hospitals? Please list name of clinic(s).

We will call to get records to update our medical records. If there are multiple vet hospitals, then please list all of them. If your pet has not been seen at another vet hospital, then can write "none".

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GP & Surgery – New Patient Form

General practice & Surgery - New Patient Form

Patient information

Patient history

After the online form is submitted, we will reach out to you within one business day to schedule the appointment.