Westridge Pet Hospital and Wellness CenterTo ensure the best care possible for your pet, please take the time to complete this form so we have as much information as possible. When done, click submit to send the form information to us.Pet Parent’s First Name* Pet Parent’s Last Name* Patient's Name* Date of Birth* MM slash DD slash YYYY Street Address City, State, Zip Home Phone* Work Phone* Mobile Phone* Email* Spouse/Partner Name Emergency Contact Name (if other than spouse) Emergency Conact's Relation to You Emergency Contact's Phone* Is this person authorized to make decisions about your pet’s health? Yes No Were you referred to Westridge by one of our clients? # of Pets in Your Household Pet Name Species Dog Cat Breed Sex Male Female Date of Birth MM slash DD slash YYYY Neutered/Spayed? Yes No Microchipped? Bordetella Date Please describe your pet's daily dietDoes your pet have any known allergies?Can you provide us with your pet's vaccination history? Please tell us what (if any) medications your pet is currently takingPlease check any symptoms or problems that you have noticed about your pet recently Behavior Problems Bleeding Gums Breathing Problems Coughing Diarrhea Eye bulging or bloodshot Gagging Lack of Appetite Lethargic Behavior Limping Loss of Balance Scooting Scratching Excessively Shaking Excessively Sneezing Thirst and/or Urination Increase Vomiting Weakness other symptoms (please explain)Please tell us the reason for your visitCAPTCHAEmailThis field is for validation purposes and should be left unchanged.