Home Pet Vet - Veterinary Care in your home serving Ashland, Phoenix, Talent, Eagle Point, Medford, White City, Central Point, Gold Hill, Jacksonville, Applegate, & Ruch Oregon

"Compassionate Pet Care at Home"

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House Call Vet Services

Serving these Jackson County cities:
Medford, Ashland, Phoenix, Talent, Eagle Point, White City, Central Point, Gold Hill, Jacksonville, Applegate & Ruch, Oregon.

Phone: 541-261-9641

Pet Health History Form

Note: Required fields are marked with an asterisk (*)

Owner Info

Owner Name

Email Address *

We will never sell or disclose your email address to anyone.

Pet History

Pet Name

Date of Birth

Type of Animal

Dog Cat Other

Sex

Male Neutered
Female Spayed

Breed

Color

Weight

Vaccinations

Please check any symptoms or problems you have noticed about your pet.

Bad Breath
Behavioral Problems
Bleeding Gums
Breathing Problems
Coughing
Diarrhea
Eyes Bulging or Bloodshot
Gagging
Lack of Appetite
Limping
Loss of Balance
Scooting
Scratching
Seems Depressed
Shaking Head
Sneezing
Thirst and/or Urination Increased
Vomiting
Weakness
Weight Problem

Other Problem

Current Medications

Describe your
pet's diet

Consent

By submitting this form, I understand that I am authorizing the Veterinarian to examine, prescribe for or treat the above described pet. I assume full responsibility for all charges incurred in the care of this animal. I understand that charges must be paid at time of service.

I agree*

Yes

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