513-793-1875
townesquarestaff@hotmail.com

Home
About
Services
Client Information
- Medical History Form
- Helpful Links
Online Pharmacy
Contact
Book Appointment

Home
About
Services
Client Information
- Medical History Form
- Helpful Links
Online Pharmacy
Contact
Book Appointment

Please note: We will be closed on Tuesday, December 24th and Wednesday, December 25th for Christmas! We will close at 3 PM on Tuesday, December 31st, and will be closed on Wednesday, January 1st for New Year’s!

Medical History Form

New Clients

Existing Clients

Owner's Name *

First

Last

Pet's Name *

Appointment Type *

In Clinic
Curbside

Best Phone Number

Best Email

I am in this vehicle

Any recent change in address, phone number(s) or email? *

If Yes, please list changes: *

Date of Appointment and Time *

Date

Time

Primary Reason for Appointment / Concern (please be as detailed as possible) *

Pet's Energy Level

Normal
Increased
Decreased

Pet's Appetite

Normal
Increased
Decreased

Food being fed:

Food brand

Amount of food fed

Recent bad breath or odd chewing?

Drinking / Water Intake

Normal
Increased
Decreased

Recent persistent coughing?

Recent persistent sneezing?

Recent persistent vomiting?

Has the pet had any recent persistent diarrhea or loose BM?

Any new lumps or bumps, and if Yes, approximate location(s):

Location(s) of bumps/lumps: *

List Medications your pet is currently taking

Do you need refills of any of these medications (Including Heartworm preventative or Flea/Tick Control Rx - please be specific):

If you need a medication refill, please list which medications

Do you need refills on any prescription pet food?

If you need a prescription pet food refill, please let us know which kind

Signature *

Clear Signature

Phone