Owner InformationOwner Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone Number*Cell Phone Number*Email Address* Best method of contact* cell phone home phone email Patient InformationPatient Name*Date of Birth* Date Format: MM slash DD slash YYYY Breed*Color*Sex*FemaleMaleFemale spayedMale neuteredOther InformationDoes your cat spend any time outdoors?*yesnoIf yes, how often and for what lengths of time?Would you like us to contact your previous veterinarian for records?*yesnoIf yes, please give the name of the doctor and/or veterinary clinicDescribe other animals in your householdVaccinations* Feline distemper 1 year Feline distemper 3 year Rabies 1 year Rabies 3 year Feline Leukemia Unknown Vaccination History If you have checked any of the above vaccinations, or have additional unlisted vaccinations, please provide date and type of vaccinationPlease check any symptoms you have noticed about your cat* Vomiting Diarrhea Increased/decreased appetite Weight gain/loss Coughing Sneezing/nasal discharge Increased urination Increased water consumption Urinating or defecating outside the litter box Spending more time apart from family members or hiding Increased vocalization at night Increased vocalization during the day Agitation or restlessness Decreased energy level Dry/dull hair coat Hair loss Other If any other symptoms, please describeDescribe Diet*Current MedicationFlea/Tick PreventionHeartworm and/or Parasite ControlAny further information you feel would be helpful to provide about your catHow did you hear of Aristokatz?*Aristokatz also offers Reiki crystal healing and Shamanic healing as a complimentary service to all our clients on Tuesdays. Are you interested in receiving this service?*YesNoI hereby authorize Dr. Katz 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 these charges must be paid in full at the time of service. Please type in your full name as a representation of your electronic signature of consent.*EmailThis field is for validation purposes and should be left unchanged. TweetPinShare11 Shares
