Cummings Veterinary Hospital

5111 Church Road
Easton, PA 18045

(610)923-0393

www.cummingsvet.com

Patient Information Form

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form. 

Thank you for your cooperation in letting us assist you.

Patient Information

Animal's Name

Animal's Name

Species
Dog
Cat
Other
Gender (required)
Male
Female
Spayed
Neutered
Age: Date of Birth

Breed

Color

Has your animal been vaccinated against the following within the last year?
Rabies
Yes
No
Date :
Clinic

Distemper
Yes
No
Date :
Clinic

Hepatitis
Yes
No
Date :
Clinic

Parvovirus
Yes
No
Date :
Clinic

Lyme
Yes
No
Date :
Clinic

Leptospirosis
Yes
No
Date :
Clinic

Fecal Exam
Yes
No
Date :
Clinic

FVRCP (Distemper/Rhinotracheitis)
Yes
No
Date :
Clinic

Heartworm/Lyme/Ehrlichia
Yes
No
Date :
Clinic

Feline Leukemia/FIV
Yes
No
Date :
Clinic

Has your pet had any drug reactions?
Yes
No

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