[ezcol_1half]Mariposa Veterinary Wellness Center
13900 Santa Fe Trail Dr.
Lenexa, KS 66215

Phone: (913) 825-3330
Fax: (913) 825-3331

Send Us A Message

We’re here to help! If you have questions about our services, appointments, or general inquiries, please feel free to reach out using the form below.

⚠ For Urgent or Emergency Concerns ⚠
Please do not use this form for urgent medical questions about your pet, as messages are not monitored in real time.

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Today's Date(Required)

MM slash DD slash YYYY

Owners Name

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Business Phone

Who recommended you to us?

GENERAL INFORMATION

Pet's name

Species

Dog

Cat

Other

If other

Age

Sex

Male - Intact

Male - Neutered

Female - Intact

Female - Spayed

If spayed or neutered at what age?

Breed

Color

Weight in lbs.

Opt Out: Check this box if you do NOT want your pet’s picture or name displayed on our website, Facebook, Twitter, or any promotional materials. We love sharing our pictures with other pet lovers!

At what age did you obtain the pet

Where did you obtain this pet? friend, breeder, pet shop (name of store), humane society, other

For what purpose was this pet obtained? Companionship, protection, breeding, show, other

Where do you take your pet for regular veterinary care (if not us)?

Time spent indoors (percent)

Outdoors (percent)

Is this pet left alone during the day?

How long?

In what area of the house or yard is the pet kept

Family home

Family away

Family asleep

When guests visit

Describe the pet's behavior

Just prior to your departure

Just after your return

Diet

% dry

Dry Brand

% canned

Canned Brand

% table scraps

Favorite treat(s)

Supplements

When is the pet fed?

By whom?

Date of last physical exam

List all major surgical or medical problems and approximate dates

List all medications (dosage, schedule & duration) that has been prescribed for a behavior problem and the results

List all medications (including dosage and schedule) currently being taken by this pet

List the number of other pets in the home

Cats

female intact

female spayed

male intact

male neuter

Dogs

female intact

female spayed

male intact

male neuter

Other

What is your pet’s relationship to the other animals (e.g. friendly, hostile, fearful)? Please describe.

What toys/types of play does the pet enjoy?

What amount of exercise or opportunity to exercise is given to the pet?

Does he or she run free in the neighborhood?

How often?

Has this pet had any formal obedience training?

Yes

Type

Class

Private instructor

I trained my pet at home

*If you selected "Private instructor", what is the name?

What type of collar do you use for training?

flat

choke chain

pinch/prong

head halter

Grade the success

failed

fair

good

excellent

Please describe the type of discipline you use for general misbehavior

What will your pet do on command?

Does this pet get along with other animals? If not, please explain.

How does this pet react to unfamiliar people?

What persons are in the pet's environment? Their schedules? Children’s ages?

BEHAVIOR PROBLEM INFORMATION

Please describe your pet's behavior problem(s):

What month/year were the problem(s) first noted?

When did it first become a serious concern?

Where and under what circumstances was each problem(s) first noted?

Describe the situation(s) in which the problem is most likely to occur?

The problems occur

when the pet is left alone

always

usually

rarely

never

in the presence of the family members

always

usually

rarely

never

during the night when the family sleeps

always

usually

rarely

never

Frequency of occurrence

Has there been a change in the frequency or intensity of the problem? Please describe

What has been done so far to correct this problem?(discipline, confine, obedience training, etc.)

What was the pet's response to the correction?

Were there any significant changes in this pet's environment prior to the appearance of this problem?

moved or redecorated

boarded

visitors (human or pet)

type of litter changed

change in family schedule

new family member/roommate

diet change

other

If other

How did these changes affect your pet?

Please indicate any other behavior problems

house soils

destructive chewing

feeding

sexual

grooming

digging

swallows nonfood items

shy

eats stool

pacing

aggressive

barking

learning

sleep

play

jumps up

unruly

bites

fights

runs away

destructive

scratching

other

If other

Please describe all situations which are likely to elicit aggressive behavior such as growling, nipping, biting, attacking, etc. (e.g. petting, approached by anyone, approached by children, only when in the car, reaching for, punishing, pushing, taking food or toys away, disturbed while sleeping, etc.):

If your pet has an aggression problem, describe at least the last two or three aggressive incidents in detail. Please discuss in detail any other information that you feel is relevant to your pet's problem:

[/ezcol_1half] [ezcol_1half_end]Business Hours
Monday-Friday: 8:00 am – 5:30 pm
Saturday: 8:00 am – 12:00 pm
Sunday: Closed
We are closed Thursday – 12:00 pm – 1:30 pm for a staff meeting.
After hours emergencies, call Overland Park Veterinary Emergency & Specialty: 913-361-3800

Our Location

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Mariposa Veterinary Wellness Center - Veterinarian in Lenexa, KS

Contact

Send Us A Message

GENERAL INFORMATION

Describe the pet's behavior

BEHAVIOR PROBLEM INFORMATION

Visit Us

Contact

Send Us A Message

GENERAL INFORMATION

Describe the pet's behavior

BEHAVIOR PROBLEM INFORMATION

Visit Us

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