Patient Intake Form
Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 512-868-2280 for a faster response.
Client Information
Full Name
*
First Name
Last Name
Primary Phone
*
Secondary Phone
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Method of Contact
Phone
Text
Email
Spouse/Co-Owner Name
First Name
Last Name
Spouse/Co-Owner Phone #
Medical History
Date of Appointment
-
Month
-
Day
Year
Date
Pet's Name
*
Species
Please Select
Canine
Feline
Age/Date of Birth
Sex
Please Select
Female
Male
Neutered Male
Spayed Female
Please enter Diet and Feeding information.
*
Please Describe Your Pet's Lifestyle
Indoor/outdoor, go to dog parks, regular boarding/daycare/grooming?
Existing Medical Conditions
Check the symptoms that your pet is currently experiencing:
*
Not eating
Trouble breathing
Trouble Defecating
Trouble Urinating
Vomiting
Diarrhea
Weight gain
Weight loss
Change in behavior
Change in activity level
Coughing
Sneezing
Increased Appetite
Increased Water Intake
Decreased Water Intake
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
While your pet is here, would you like us to add:
Nail Trim
Nail Dremel
Anal Gland Expression
Microchip
Please indicate what preventatives or medications you need a refill of:
Heartgard
Nexgard
Bravecto
Other
Are you interested in any of the following preventative care for your pet today? (Select all that apply)
*
Rabies Vaccine
Distemper Vaccine
Bordetella Vaccine
Influenza Vaccine
Leptospirosis Vaccine
Feline Leukemia Vaccine
Intestinal Parasite (Fecal) Lab test
Heartworm/Tick Borne Disease Test
Annual Full Organ Function Lab Screening
Urinalysis
Other
Are there any other issues/concerns that you would like to discuss at your appointment?
Is there a previous Vet that we can contact for records?
I give permission for Castlerock Pet Hospital to share photographs or case specific information about my pet in all media (including promotion, advertising, sale, publicizing, and general marketing of Castlerock Pet Hospital).
*
Yes
No
Signature
Submit
Submit
Should be Empty: