Patient Registration | Companion Animal Wellness Center

New Patient Registration Form

Please fill this out and submit prior to your appointment, thank you. You can reach us at 760-444-0342.

Owner First Name

Owner Last Name

Phone number where you can be reached

Pets Name

Pets Birthdate (can be approx.)

Pets Gender (male or female)

Spayed/Neutered?

What diet are you currently feeding? (commercial raw, commercial cooked, home prepared, canned, freeze dried, kibble). How long has your pet been on this diet?

What time of the day is your pet being fed? How often? How much?

When did you pet last receive bloodwork or other diagnostics? (x-rays, CT scan, biopsy, cytology etc.)

For Canines, when did your pet receive their last heartworm/tickborne disease test?

Current Medications (please include how much & how often medication is given)

Current supplements

Flea/Tick Prevention

Heartworm Prevention

Is your pet indoor/outdoor?

Are there any other animals in the household?

Is your pet fearful, anxious, and/or aggressive? (Explain)

Any other behavioral tendencies that would be helpful for us to know?

Any major medical events/surgery?

What brings you to our practice today, or what specific concerns would you like to discuss?

What is the main goal you'd like to reach with this visit?

What are your expectations for our consultation?

If you are coming in for a second opinion consultation, who is your regular veterinarian?

Please provide a contact number for your primary veterinarian and any specialists (if applicable). If you are coming in for a second opinion consultation, it is helpful for you to bring a copy of your pets records with you for your appointment. Thank you

How did you hear about us?

Thank you so much, we look forward to meeting you!