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 Wednesday, December 24th and Thursday, December 25th in observance of Christmas, will observe limited hours on Friday, December 26th from 9:00 am – 2:00 pm, will close early on Wednesday, December 31st at 3:00 pm, and will be closed on Thursday, January 1st in observance of 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 brand

Amount of food fed per feeding

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?

If yes, explain details – duration, consistency, accidents *

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

Location(s) of bumps/lumps: *

Any new mobility or limping concerns? *

If yes, explain which leg, duration, severity, etc. *

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

Website