New Patient Form

Patient Information

Patient Name*

Microchip #

Color/Markings*

i.e., brown tabby, calico, black & white

Breed*

i.e., long hair, short hair, Siamese, Ragdoll. If unknown then simply say "Unknown"

Sex*

Male

Male Neutered

Female

Female Spayed

Unknown

Declawed*

Not Declawed

Front Only

Front & Back

Age/Date of Birth*

Let us know if you are guessing

Is your cat...?*

Indoor Only

Indoor/Outdoor (free-roaming)

Indoor/Outdoor (only on leash or supervised, or barricaded yard)

Indoor/Catio

Other

Where did your feline companion come from?*

Shelter/Rescue

Breeder

Pet Store

Stray

Other

What age was your kitty when he/she came into your life?*

Describe Kitty's Personality*

Kitty's Prior Veterinarian/Hospital
We will handle getting kitty's previous medical records (no need for the address, etc. on Boulder County Hospitals). Please list ALL hospitals including emergency and specialist hospitals. Yes, we really want them all.

Veterinarian/Hospitals (list name/address/phone/email)

Medical Problems
List and describe any known current or past medical problem, illness or injury.

Name/Description of Problem/Illness/Injury 1

Onset Date

Approximate date OK

Resolved?

Yes

Unsure

Name/Description of Problem/Illness/Injury 2

Onset Date

Approximate date OK

Resolved?

Yes

Unsure

Foods/Treats

Diet 1: Is your kitty currently eating this or was this in the past?*

Current

Past

Diet Type*

Raw

Canned

Kibble

Non-kibble, Dry

Other

Brand*

Tiki Cat, Smallbatch, etc

Variety*

Paw Lickin Chicken, Chicken chubs, etc.

Diet 2: Is your kitty currently eating this or was this in the past?

Current

Past

Diet Type

Raw

Canned

Kibble

Non-kibble, Dry

Other

Brand

Tiki Cat, Smallbatch, etc

Variety

Paw Lickin Chicken, Chicken chubs, etc.

Medication and Supplement Information

Is your cat currently on any medications or supplements?**

Yes

Medication #1(Include name, strength, dose, frequency):

Ex: Carprofen 75mg, one tablet twice a day

Medication #2(Include name, strength, dose, frequency):

Ex: Carprofen 75mg, one tablet twice a day

New Patient Form

Patient Information

Patient Name*

Microchip #

Color/Markings*

Breed*

Sex*

Declawed*

Age/Date of Birth*

Is your cat...?*

Where did your feline companion come from?*

What age was your kitty when he/she came into your life?*

Describe Kitty's Personality*

Kitty's Prior Veterinarian/Hospital We will handle getting kitty's previous medical records (no need for the address, etc. on Boulder County Hospitals). Please list ALL hospitals including emergency and specialist hospitals. Yes, we really want them all.

Veterinarian/Hospitals (list name/address/phone/email)

Medical Problems List and describe any known current or past medical problem, illness or injury.

Name/Description of Problem/Illness/Injury 1

Onset Date

Resolved?

Name/Description of Problem/Illness/Injury 2

Onset Date

Resolved?

Foods/Treats

Diet 1: Is your kitty currently eating this or was this in the past?*

Diet Type*

Brand*

Variety*

Diet 2: Is your kitty currently eating this or was this in the past?

Diet Type

Brand

Variety

Medication and Supplement Information

Is your cat currently on any medications or supplements?**

Medication #1(Include name, strength, dose, frequency):

Medication #2(Include name, strength, dose, frequency):

Are there any other details you would like to add?

Kitty's Prior Veterinarian/Hospital
We will handle getting kitty's previous medical records (no need for the address, etc. on Boulder County Hospitals). Please list ALL hospitals including emergency and specialist hospitals. Yes, we really want them all.

Medical Problems
List and describe any known current or past medical problem, illness or injury.