Name: New Ulm Regional Veterinary Center
Address: 401 20th S St, New Ulm, MN, 56073, US
Telephone: (507) 233-2500

Sick or Injured Pet Visit

Complete and submit the online form.

Cat

First Name *

Last Name *

Phone Number *

Email Address *

Pet's Name *

Do you have an appointment? *

Yes

No

Date of Appointment (N/A if you do not have an appointment) *

What problem(s) is/are your pet experiencing? *

When did the problem start? *

Is the problem the same, better, or worse? *

Has a similar problem happened in the past? *

Yes

No

Eating Changes *

Increased

Decreased

Stayed the same

Has your pet experienced any weight loss? *

Yes

No

Any increase or decrease in water consumption? *

Increase

Decrease

Stayed the same

Any change in bowel movements? *

Any exposure to toxins? *

Any other medical history? *

Is your pet currently taking any medications? *

Yes

No

What medications is your pet on? (Enter N/A if not applicable) *

Do you have insurance for your pet? *

Yes

No

Undecided

Additional Comments

What type of food do you feed your pet? *

What is the feeding schedule? (How much AND how often, or is it free choice?) *

Is your pet mainly indoor or outdoor? *

When is the last time you dewormed your cat? *

Flea and Tick preventive

Do you use a flea & tick preventive *

Yes

No

What brands? (Enter N/A if not applicable) *

Date last given? (Enter N/A if not applicable) *

Do you need a flea & tick preventative refill? *

Yes

No

If yes, number of doses?

Does your cat use the litter box appropriately? *

Yes

No

Does your pet go to or do any of the following? *

Boarding

Grooming

Hunting

Exposure to ticks

None

Do you have any specific concerns?

Please list all the pets you currently own

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Dog

First Name *

Last Name *

Phone Number *

Email Address *

Pet's Name *

Do you have an appointment? *

Yes

No

Date of appointment? (Enter N/A if not applicable) *

What problem(s) is/are your pet experiencing? *

When did the problem start? *

Is the problem the same, better, or worse? *

Has a similar problem happened in the past? *

Yes

No

Eating Changes *

Increased

Decreased

Stayed the same

Has your pet experienced any weight loss? *

Yes

No

Any increase or decrease in water consumption? *

Increase

Decrease

Stayed the same

Any change in bowel movements? *

Any exposure to toxins? *

Any other medical history? *

Is your pet currently taking any medications? *

Yes

No

What medications is your pet on? (Enter N/A if not applicable) *

Do you have insurance for your pet? *

Yes

No

Undecided

Additional Comments

What type of food do you feed your pet? *

What is the feeding schedule? (How much AND how often, or is it free choice?) *

Is your pet mainly indoor or outdoor? *

Heartworm Preventative

Do you use heartworm preventative? *

Yes

No

What brands? (Enter N/A if not applicable) *

Date last given? (Enter N/A if not applicable) *

How often? *

Seasonal

Year-round

Currently not using

Do you need a refill? *

Yes

No

If yes, how many doses?

Flea and Tick preventive

Do you use a flea & tick preventive *

Yes

No

What brands? (Enter N/A if not applicable) *

Date last given? (Enter N/A if not applicable) *

Do you need a flea & tick preventative refill? *

Yes

No

If yes, number of doses? (Enter N/A if not applicable)

Does your pet go to or do any of the following? *

Boarding

Grooming

Dog Park

Hunting

Exposure to ticks

None

Do you have any specific concerns?

Please list all the pets you currently own

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Other

First Name *

Last Name *

Phone Number *

Email Address *

Pet's Name *

Type of pet? *

Do you have an appointment? *

Yes

No

Date of appointment? (Enter N/A if not applicable) *

What problem(s) is/are your pet experiencing? *

When did the problem start? *

Is the problem the same, better, or worse? *

Has a similar problem happened in the past? *

Yes

No

Eating Changes *

Increased

Decreased

Stayed the same

Has your pet experienced any weight loss? *

Yes

No

Any increase or decrease in water consumption? *

Increase

Decrease

Stayed the same

Any change in bowel movements? *

Any exposure to toxins? *

Any other medical history? *

Is your pet currently taking any medications? *

Yes

No

What medications is your pet on? (Enter N/A if not applicable) *

Do you have insurance for your pet? *

Yes

No

Undecided

Additional Comments

What type of food do you feed your pet? *

What is the feeding schedule? (How much AND how often, or is it free choice?) *

Do you have any specific concerns?

Please list all the pets you currently own

Spam Blocker

Sick or Injured Pet Visit Form

Sick or Injured Pet Visit

Flea and Tick preventive

Heartworm Preventative

Flea and Tick preventive

Welcoming New Ulm Animals to our Animal Hospital