Patient History Form

Save time during your next appointment. Complete your required patient history form online from any device before your visit.

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Patient History Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet before your visit.

Pet's Name *

Client Name *

First

Last

Date of your Appointment *

Phone *

Email *

Reason for Visit *

Has your pet been examined elsewhere for the same condition?

If yes, where? *

When did the issue first begin? *

Is the issue

Improving
Continuing (stable or unchanging)
Worsening

Has your pet had any of the following issues (check all that apply)?

Coughing
Sneezing
Vomiting
Diarrhea
None of the above

Has your pet had any of the following (check all that apply)?

New lumps or bumps
Behavior changes
Changes in mobility
None of the above

My pet’s appetite is

Normal
Increased
Decreased

My pet’s activity level is

Normal
Increased
Decreased

My pet’s thirst level is

Normal
Increased
Decreased

Has your pet’s urination/defecation habits changed?

Current Diet *

Amount & Frequency of Feeding *

What medication(s) and/or dietary supplements is your pet currently taking? *

Is your pet allergic to any food or medications?

Has your pets diet changed in the last 6 months?

Yes
No
Unsure

Is your pet

Indoor only
Mostly indoor but rarely goes outdoors
Indoor/outdoor
Outdoor only
Outdoor during the day/inside at night
Other

If other, please specify *

Does your pet have any known health concerns or chronic conditions? *

Do you have any concerns that you would like to bring to the doctors attention or areas that you would like the doctor to pay special attention to while your pet is with us? *

Is there anything else you would like to discuss at your appointment? *

Do you have pictures or videos that would help us with your pet's exam?

Click or drag a file to this area to upload.

Schedule An Appointment

We proudly serve the pets of the Gardner, Templeton, Winchendon, Phillipston, Royalston, Westminster, Ashburnham, Athol, Hubbardston, Princeton, Barre, Rutland, and surrounding communities. We look forward to seeing you and your pets. Request an appointment by clicking the button below.

Appointment

Have Questions?

Get in touch. We look forward to hearing from you.

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Location

7 Pearson Blvd
Gardner, MA 01440

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Contact Information

Call and Text: 978-632-0024
Fax: 978-632-0064
Email: Frontdesk@tenderheartvetcare.com

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Hours

Monday-Friday: 8 AM – 5 PM
Saturday: Closed
Sunday: Closed

Name *

First

Last

Email *

Phone

How can we help you? *

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