Canine Epilepsy Intake Form
Please provide detailed information about your dog and their epilepsy history to help us prepare for your visit.
Owner Full Name
*
First Name
Last Name
Owner Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Owner Email Address
*
example@example.com
Dog's Name
*
Dog's Date of Birth (or approximate age)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dog's Breed
Dog's Sex
Male
Female
Neutered/Spayed
Intact
When did your dog first start having seizures? (approximate date)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Describe your dog's seizures (what happens, how long they last, frequency)
*
How often does your dog have seizures?
*
Please Select
More than once per week
Once per week
Every 2-4 weeks
Every 1-3 months
Less than once every 3 months
Is your dog currently taking any medications or supplements for epilepsy?
*
Yes
No
If yes, please list all current medications and supplements (name, dose, frequency)
Has your dog been diagnosed or treated for epilepsy by another veterinarian?
*
Yes
No
If yes, please provide details (diagnosis, treatments, clinic name if known)
Have you noticed any specific triggers for the seizures?
Excitement
Stress
Certain foods
Environmental factors (lights, sounds)
No known triggers
Other
Does your dog have any other medical conditions or past illnesses?
Please describe your dog's typical diet (brand, type, treats, feeding schedule)
Upload any relevant medical records, test results, or videos (optional)
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Additional notes or concerns
Submit Intake
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