Veterinary Intake Form
Medical History
Full Name
*
First Name
Last Name
Pets Name
Phone Number
*
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Please enter Diet and Feeding information.
*
Check the conditions that apply to your pet.
*
Coughing
Sneezing
Vomiting
Diarrhea
Eye Discharge
Dirty/Itchy Ears
Nasal Discharge
Limping
Skin Issue
New or changed lump
No concerns
Other
How long has this condition been going on for and with what frequency?
Has your pet experienced this condition in the past?
Please Select
Yes
No
Check the symptoms that your pet is currently experiencing:
*
Not eating
Trouble breathing
Trouble Defecating
Trouble Urinating
Weight gain
Weight loss
Change in behavior
Change in activity level
No concerns
Other
How long has this symptom been going on for and with what frequency?
Has your pet experienced this symptom in the past?
Please Select
Yes
No
Please list all medications/vitamins/supplements/preventatives that your pet is currently taking.
Has your pet ever had a reaction to vaccinations?
*
Yes
No
Not Sure
Please indicate what preventatives or medications you need a refill of:
Heartgard
Frontline
Nexgard
Revolution
Other
Which preventative care procedures are you approving? (Select all that apply)
*
Rabies Vaccine
Distemper Vaccine
Bordetella Vaccine
Influenza Vaccine
Lyme Vaccine
Leptospirosis Vaccine
Feline Leukemia Vaccine
Intestinal Parasite (Fecal) Lab test
Heartworm/Tick Parasitology (Blood) test
Annual Full Organ Function Lab Screening
Urinalysis
Other
Are there any other issues/concerns that you would like to discuss at your appointment?
A topical treatment will be applied at my expense to any pet with evidence of fleas, flea dirt, or ticks. I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital.
Please type in your initials
Signature
Submit
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