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First Name*:
Last Name*:
Email Address*:
NorthStar VETS Location: Robbinsville Maple Shade
Patient Name*:
What cancer has your pet been diagnosed with?
What was the first sign that you saw if any?
How long has your pet had these signs? days/weeks/months/years
Has your pet had a biopsy or fine needle aspirate of his/her cancer? Yes No
If yes, do you have results with you? Yes No faxed by my regular veterinarian
Has your pet had bloodwork performed in the last month? Yes No
Has your pet had radiographs (xrays) performed in the last month? Yes No
If yes, do you have results with you? Yes No emailed by my regular veterinarian
Has your pet had any other tests performed in the last month? Yes No
What test(s)?
Do you have any other pets? Yes No
Please put breed and ages of other pets:
Is your pet on flea/tick preventative? Yes No
Is your pet on heartworm preventative? Yes No
For cats: Has your pet been tested for FeLV/FIV? Yes No
If yes, at what age was your pet tested
Has surgery been performed to remove the cancer? Yes No
If yes, what was the date of this surgery:
Does your pet have any other previously diagnosed medical or surgical problems unrelated to the cancer? Yes No
If yes, please describe:
Please list all medications that your pet is on, doses (if you know), how often and for how long your pet has been on the medication. Please include Drug, Pill size (mg), How often and How long has he/she been on this medication?
Have you noticed any change in the health or behavior of your pet that coincided with the development of the cancer? (e.g. changes in food or water intake, changes in urination or defecation, changes in activity level? Yes No
If yes, please list:
Describe the current diet of your pet including brand names and any table foods, treats, biscuits, vitamin supplements, or rawhide chews given?
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