Country Doctor Veterinary Hospital

6807 Weiss Road
New Tripoli, PA 18066

(610)298-2520

cdvh.com

*First Name
*Last Name
*Patient Name
*Species
*Breed
*Color
*Sex
Date Of Birth

The following is for Dog Medical History Only

Please note last vaccine or test date and test result.
Rabies Vaccine
DHPP Vaccine
Leptospirosis Vaccine
Lyme Vaccine
Kennel Cough/Bordetella Vaccine
Fecal (stool sample)
Heartworm Test
Heartworm Prevention Brand

The following is for Cat Medical History Only

Please note last vaccine or test date and test result.
Rabies Vaccine
FVRCPC Vaccine
FIP Vaccine
Feline Leukemia Vaccine
Leukemia Test
FIV Test
Fecal (stool sample)

If your pet is not a dog or cat, please note any vaccines or tests that he/she has recieved.
Rabies Vaccine
Distemper
Other

Please answer the following questions.
*Does your pet have any previous illnesses or surgery?
*Does your pet have any pre-existing medical conditions?
*Does your pet have any allergies to medications or vaccinations?
*Is your pet on any special diet or medication?
*Does your pet have a tattoo or microchip? If yes, please note the number and location.
*Do you wish for us to contact your previous veterinarian in order to obtain your pet's medical records? Y/N
If yes, please note the veterinarian's office name.
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