Cat Clinic and Hospital

5170 Liberty Avenue, Pittsburgh, PA  15224

Tel: (412) 681-1122


New Patient Form

Please call for an appointment before filling out and submitting this form:  (412) 681-1122

Owner Information

Yes No
Yes No

If there is another person responsible for the care of this cat, and with whom we may discuss this cat’s medical condition and needs, please fill out the following for that person.

Patient Information

DSH, DLH, Siamese, Persian, Bengal, Abyssinian, etc.

Female Spayed
Male Neutered
Wet Dry

Patient Medical History

Provide Dates for the following
Positive Negative
Vomiting Change in appetite
Constipation Difficulty urinating
Sneezing Eye discharge
Itching Skin growth
Changes in behavior Diarrhea
Change in weight Frequent urination
Lethargy Coughing
Vision problems Hair loss
Lump or mass

How many pets in your household?

Yes No


I HEREBY GRANT PERMISSION TO the Cat Clinic and Hospital staff to examine and treat my cat. I assume responsibility for the charges incurred in the treatment/care of my cat as discussed with the veterinarian and/or veterinary technicians. Full payment is due at the time of your cat’s evaluation, treatment, and/or discharge. We accept cash, Visa and Mastercard. Checks are accepted with prior approval by management.

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