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27 Buckley Highway
Stafford Springs, CT 06076
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Dr. David Mordasky
Dr. Andrew Mordasky
Dr. Liz Nutile
Dr. Nicole Davies
Staff
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Contact
Menu
Home
SMALL ANIMAL
Canine Wellness Care
Feline Wellness Care
Dentistry
Diagnostics
Exotic Pets
Microchipping
Nutrition and Diet
Poultry and Birds
Surgery
Therapeutic Laser
Vaccines
LARGE ANIMAL
Ambulatory Services
Equine Services
Livestock
Small Ruminants
Client Resources
Online Reviews
New Client Welcome Packet
Surgical Information Packet
Online Client Forms
Canine History Form
Feline History Form
Canine/Feline Surgical Release Form
About
Dr. David Mordasky
Dr. Andrew Mordasky
Dr. Liz Nutile
Dr. Nicole Davies
Staff
Practice Culture
Contact
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Client Resources
Client Resources
New Client Welcome Packet
Online Reviews
Canine History Form
Feline History Form
Canine/Feline Surgical Release Form
Menu
Client Resources
New Client Welcome Packet
Online Reviews
Canine History Form
Feline History Form
Canine/Feline Surgical Release Form
Feline History Form
All fields are required
Owner Name
*
First
Last
Owner Email
*
Patient Name
*
Age of Pet
*
Sex
*
Male
Female
Altered
*
Yes
No
Is allowed to go outside
*
Yes
No
Occasionally escapes
*
Yes
No
Stays indoors all the time
*
Yes
No
Lives with other cats
*
Yes
No
Comes into contact with other cats
*
Yes
No
Is boarded
*
Yes
No
I am likely to get an additional cat soon
*
Yes
No
Maybe I will get another cat someday
*
Yes
No
I plan never to get an additional cat
*
Yes
No
Sometimes has access to the food dish, water bowl, or litter box of other cats
*
Yes
No
Brand of food given
*
How much food is given?
*
How often is food given
*
Allergies/Reactions to Medication or Vaccination
*
Yes
No
If "Yes" above please explain
Current Medications
Flea Control Used
*
Frontline/Advantix
Cheristan
Vectra
Comfortis
Bravecto
Other
Heartworm Control
*
Heartgard
Advantage Multi
Revolution
Other
Please explain reason for visit
*
Subjective
Appetite
*
Decreased
Increased
Normal
Water Consumption
*
Decreased
Increased
Normal
Bowel Movements
*
Constipated
Normal
Diarrhea
Urination
*
Decreased
Normal
Increased Frequency/Amount
Incontinence (Loss of Housetraining)
*
Yes
No
Lethargy
*
Yes
No
Behavioral Changes
*
Yes
No
If "Yes" to behavioral changes please explain
Bad Breath
*
Yes
No
Scratching
*
Yes
No
If "Yes" to scratching please explain location
Significant Hair Loss
*
Yes
No
If "Yes" to hair loss please explain location
Unusual Lumps/Bumps
*
Yes
No
If "Yes" to lumps/bumps please explain location
Vomiting
*
Yes
No
Coughing/Gagging
*
Yes
No
Sneezing
*
Yes
No
Shaking Head
*
Yes
No
Unusual Discharge
*
Yes
No
If "Yes" to unusual discharge please explain location
Lameness
*
Yes
No
If "Yes" above which leg?
RF
LF
RR
LR
Difficulty Rising
*
Yes
No
Scooting
*
Yes
No
Any Seizure Activity
*
Yes
No
If "Yes" to seizure activity How Often?
When was last seizure?
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