Dr. Cathy Harmon

517 West Central AvenueDr. Tim Harmon

Andover, Kansas 67002Dr. Kate Perkins

(316) 733-0701Dr. Johna Unruh

Welcome To Our Office

Today’s Date
Name / Spouse/Other Name:
Address:
Street Address / Apartment/Unit #
City / State / ZIP Code
Phone / ( ) / ( ) / ( )
Home / Work / Other Phone (Please Specify)
Emergency Contact # / Email
Best time/place to call you regarding your pet’s care
Pet Information
Name / Breed / M/F/MN/FS / Age
How did you hear about us?
□ Personal Referral by Friend, Relative, etc. (Who shall we thank?)
□ AT&T Yellow Pages
□ Fiest Yellow Pages / Where did you get your pet?
□ Civic Group or Community Event / How long have you owned your pet?
□ Sign (Drove By) / What food does your pet eat?
□ Newspaper (which paper?) / Canned or dry?
□ Internet (website, facebook, web search, etc.) / Is your pet fed any table scraps? (people food)
□ Welcome Card Program / How often do you bathe/brush your pet?
□ Pet Store/Humane Society / How much time does your pet spend outdoors?
□ Direct Mail (what piece?) / Where does your pet sleep?
How many hours per day is the family with your pet?
How do you view your pet in terms of health concerns issues? / What prior illness or health issues has your pet had?
□ As a family member (I am concerned about all health
issues/recommendations)
□ As a pet (I am not concerned about all preventative and wellness
issues)
Is your pet spayed or neutered? / No / Yes / Check any of the following that are a concern for your pet
If no, do you plan to have it done? / No / Yes / □ excessive barking / □ straying from home
Do you plan to breed your pet? / No / Yes / □ house breaking / □ itching/scratching
Does your pet have any drug allergies? / No / Yes / □ wetting/spraying in the house / □ overly rambunctious
Did you bring previous medical records? / No / Yes / □ problems around children / □ biting
Do you take your pet with you on vacation? / No / Yes / □ shedding / □ clawing or digging
Will you ever need to board your pet? / No / Yes / □ jumping / □ bad breath
Do you use your pet for hunting? / No / Yes / □ Other ______
Is your pet on a preventative program for / Which of the following services might you utilize?
fleas and ticks? / No / Yes / □ lodging/boarding facility / □ evening hours
Is your pet on preventative for internal / □ referral rewards program / □ grooming
parasites (Heartworm/Intestinal Worms)? / No / Yes / □ behavior training classes / □ day care
Does your pet spend long periods alone / □ value package programs / □ product trials
during the day? / No / Yes
Has your pet been microchipped? / No / Yes
Has your pet ever had dental care? / No / Yes
Do you know how dental care can extend
the life of your pet? / No / Yes
Do you have veterinary care insurance? / No / Yes