Portland Veterinary Oncology Center

13655 SW Jenkins Road
Beaverton, OR 97005

(503)644-6581

portvetonc.com

New Patient Fillable Form Form

Name (required)
First Name (required)
Last Name (required)
Pet's Name (required)

Species
Dog
Cat
Breed

Sex
Male
Neutered
Female
Spayed
Where did you obtain your pet?

How long have you owned your pet?

Where is your pet housed?
Indoors
Outdoors
Both
Purpose of pet?
Pet
Show
Sport
Guard
For intact females: when was your pet's last heat cycle?

Approximately when was your pet neutered/spayed?

What is your pet's current diet? (Brand)

Does your pet have contact with other animals?

Has your pet ever traveled outside of OR?

What medications is your pet currently receiving and at what dose?

Has your pet had any bad reactions to medications? If so, what medications?

What illnesses, injuries or surgeries has your pet had prior to the current problem?

Is your pet currently coughing or sneezing?

Has there been any changes in your pet's willingness to play or exercise?

Is your pet vomiting?

Has there been any recent change in your pet's appetite?

Has your pet lost or gained weight recently?

Has there been any changes in your pet's urinary habits?

Have you noticed a change in the amount of water your pet drinks?

Are there any other lumps that have been found on your pet?

If yes, have they been aspirated or biopsied?

Where are the masses located on your pet?

Is there anything else that you would like us to know about your pet?


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