Skip to content
Adopt a Pet
Shop
(214) 494-0045
Home
About
Mission & Purpose
Board of Directors & Staff
Services
Overview & Pricing
Veterinary Assistance Program
The Angel Care Fund
Feral Cat Program
Donate
Sponsor
Contact
Home
About
Mission & Purpose
Board of Directors & Staff
Services
Overview & Pricing
Veterinary Assistance Program
The Angel Care Fund
Feral Cat Program
Donate
Sponsor
Contact
Request Appointment
Pre-Surgery or Appointment Form
General Information
Owner's Full Name
(Required)
Email
(Required)
Phone
(Required)
Pet's Name
(Required)
How long have you owned your pet?
(Required)
When and what time was your pet’s last meal?
(Required)
Canine Patients
Has your pet been tested for heartworms?
Yes
No
When was the heartworm test?
MM slash DD slash YYYY
What were the results?
Negative
Positive
Is your pet currently on monthly heartworm prevention?
Yes
No
Please check off the activities your dog participates in:
Boarding
Grooming
Training Classes
Dog Parks
Being a “Social Butterfly”
Hiking
Swimming
Dogs should be vaccinated against Bordetella (a.k.a. kennel cough) if their lifestyle includes any or all of the above activities. Kennel cough is a contagious disease that is most commonly spread in areas where lots of dogs spend time together, but it can also be picked up from casual contact with other dogs.
Dogs should be vaccinated against Lepto. Lepto is carried by wildlife such as rats, raccoons, opossums, skunks, squirrels, and deer. It is found in places where they might urinate, including lakes, streams, puddles or soil in your backyard.
Feline Patients
Has your pet been tested for FeLV and/or FIV?
Yes
No
When was the FeLV and/or FIV test?
MM slash DD slash YYYY
What were the results?
Negative
FELV Positive
FIV Positive
What kind of lifestyle will your cat be living, both now and in the future?
Indoor Only
Indoor & outdoor
Living with cats that go outdoors
Not Sure
Cats should be vaccinated against Feline Leukemia if they spend time outdoors, or if they live with cats that go outdoors, unless they are always supervised on a leash. Feline leukemia is a contagious disease that requires prolonged direct contact with an infected cat, making cats that go outdoors the most at risk. Kittens and young cats are more at risk than older adults.
Additional Information
Is your pet current on any vaccines?
Rabies
Distemper/Parvo
Bordetella
FVRCP
FeLV
Vaccines and Dates Administered
Please list one per line
Upload Vaccine Medical Records
Drop files here or
Select files
Max. file size: 50 MB.
Has your pet been de-wormed?
Yes
No
Routine de-worming is highly recommended for puppies and kittens during their initial vaccine series and for adults at least once a year.
When was the de-worming?
MM slash DD slash YYYY
Please list any related medications to de-worming:
Is your pet currently taking any medications?
Yes
No
If yes, what medications?
Has your pet ever had an allergic reaction to a vaccination or any medication?
Yes
No
When was the allergic reaction?
MM slash DD slash YYYY
What was the allergic reaction to?
Has your pet been diagnosed with a medical condition?
Yes
No
(Conditions include: Seizures, skin conditions, heart, kidney, and/or liver conditions, etc.)
What condition?
Has your pet had any surgeries?
Yes
No
Please explain past surgery(s)
Female patients: Is your pet possibly in-heat or pregnant?
Yes
No
Does your pet live inside or outside?
Inside
Outside
Both
Email
This field is for validation purposes and should be left unchanged.
Δ
