Your Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email Address *

Cell Phone Number *

Other Phone Number

Preferred contact method? *

Text
Email
Cell Phone
Other

If other:

How did you hear about us? *

Google Search
Facebook
Instagram
Referred by
Other

If other or referral please specify:

Co-Owner Information

This can be a partner, friend or anyone with whom you share ownership of your cat.

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email Address

Cell Phone Number

Is this person authorized to make decisions about your cat's healthcare?

Your Cat’s Information

Cat's Name *

Date of Birth OR Approximate Age

Breed (if known)

(*Most domestic cats are mixed breeds, and are referred to as domestic short hair, domestic medium hair, and domestic long hair.)

Fur Color(s)

Gender *

Has your cat been spayed (female) or neutered (male)? *

Yes
No
Don’t know

Does your cat have a microchip or other form of permanent identification? *

Yes
No
Don’t know

If yes, please supply microchip number (if known) or describe other form of identification

Does your cat have insurance?

If yes, please provide the insurance company name and policy number *

How did you obtain your cat?

Please describe if other:

When did you get your cat (approximate date)?

Please attach a picture of your cat here or send a photo to hello@atriumcathospital.com with your cat’s first and last name in the subject line.

Click or drag files to this area to upload. You can upload up to 2 files.

Health History

Does your cat have any known allergies?

If yes, please describe

Does your cat have any pertinent past medical history that we should be aware of (major illness or injury, adverse reaction to medication or anesthesia, other)? *

If so, please explain *

Medical Records

We will request records from any veterinary practices your cat has visited in the past 24 months. Please provide the name, city, state and phone number for each practice.

Enter Vet Information

Medications and Supplements

Medications: Please list all medications your cat is currently taking. Include all prescription and over the counter medications given by mouth, by injection, or applied to the skin, eyes, or ears, even if they are only used infrequently. Example: Methimazole, 2.5 mg twice a day for 5 years

Lifestyle

Does your cat have any access to the outdoors via the following (check all that apply): *

No outdoor access
Free roaming
An enclosure such as a catio or screened porch
Leash walking
Other

If other please describe:

Does your cat have direct exposure to other cats via the following (check all that apply): *

No exposure to other cats
Housemates
Visiting cats
Foster cats
Other free roaming cats
Other

If other please describe:

Does your cat (check all that apply):

Visit boarding or grooming facilities
Attend cat shows or similar events

Are there other pets in the household? *

If so, please list:

Nutrition and Activity

How active is your cat?

Very active
Moderately active
Not very active

How would you describe your cat’s weight?

Overweight
Ideal weight
Underweight

Does your cat have any dietary restrictions?

If so, please explain:

Please list ALL cat food, treats, snacks, dental hygiene products, and any other foods that your cat currently eats, including foods or treats used to administer medications. Example: Purina ONE Plus Hairball Formula Dry *

Visiting the Vet

During travel to the veterinary hospital, does your cat do any of the following:

Hide
Drool
Vomit
Urinate
Defecate
Meow
Pant
Tremble
Pace
Scratch
Other

If other please describe:

Which of the following situations have been particularly stressful for you and/or your cat during previous veterinary visits? How did your cat react? You can add comments at the end.

Waiting with other people and animals in the waiting area
Getting out of the carrier
Being approached by veterinary staff
Loud sounds
Having direct eye contact with the technician and/or veterinarian
Being taken out of the exam room for procedures
Blood sampling
Nail trims
Petting/brushing
Other

If other, please describe.

How did your cat react?

Has your cat ever been prescribed supplements or medications to help ease anxiety associated with a visit to the veterinary hospital? *

If so, which one(s), and what was the result?

Does your cat have any sensitive areas that s/he does not like to have touched? *

Signature *

Date *

Social Media & Promotional Materials

I do / do not (select one) hereby grant and authorize Atrium Cat Hospital permission to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of my cat to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, brochures, advertisements, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration. Cats will be identified only by their first names. This authorization extends to all languages, media, formats and markets now known or later discovered. This authorization shall continue indefinitely, unless I otherwise revoke this authorization in writing. I waive the right to inspect or approve any finished product in which my cat’s likeness appears, including written or electronic copy. *

I Do
I Do Not

Signature (copy) *

Date (copy) *

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