Client Name
First Name
Last Name
Day Admission
Canine or Feline
Phone number to contact on the Day of Admission
-
Area Code
Phone Number
Alternate phone number for contact
-
Area Code
Phone Number
HAVE YOU BEEN EXPOSED TO SOMEONE WITH COVID?
Yes
No
Email
example@example.com
How do you plan on paying for your invoice today?
Credit card
Check
Cash
Care Credit
Do you have an appointment or are you here to be seen as a walk-in?
Appointment
Walk-in
Pet's name and Date of Birth
Name
Birth date
When did the problem start?
-
Month
-
Day
Year
Date
Please describe primary reason for Appointment/Concerns
Is your pet Vomiting?
Yes
No
Occasionally
If yes, please describe below
Is your pet having Diarrhea?
Yes
No
Occasionally
If yes, please describe below
Have you given your pet any medication? If yes, please list what medication and when.
How is your pet EATING?
1
2
3
4
5
Eating LESS than usual
Eating MORE than usual
1 is Eating LESS than usual, 5 is Eating MORE than usual
Is your pet more THIRSTY than usual?
1
2
3
4
5
Drinking LESS than usual
Drinking MORE than usual
1 is Drinking LESS than usual, 5 is Drinking MORE than usual
Patient's energy level
1
2
3
4
5
Lethargic
Very active
1 is Lethargic, 5 is Very active
Patient's Urination (select all that apply)
Normal
Increased
Decreased
Blood present
Dark
Straining to urinate
Strong/foul odor
Please rank how PAINFUL you think your pet is?
1
2
3
4
5
Not painful
Very painful
1 is Not painful, 5 is Very painful
Is the patient on Heartworm Prevention?
Yes
No
I'm not sure
If your dog is on Heartworm Prevention, when was the last dose given?
Is the patient coughing or sneezing?
Coughing
Sneezing
Coughing AND sneezing
None of the above
Do you need refills on any medications? If so, which ones?
What flea/tick preventive are you using?
Have you seen any fleas or ticks on your pet?
Yes
No
Do you provide dental care for your pet? If yes, please describe below.
Yes
No
If the patient is a cat, does he/she go outside?
Indoor only
50/50 Indoor/Outdoor
Outdoor only
My cat does have contact with other cats
My cat does NOT have contact with other cats
What brand of food do you feed your pet and how much do you feed daily?
If the patient is a dog, does he/she go to the following:
Boarding facility
Groomer
Dog Park
Obedience/Training class
Have contact with any other dogs outside of house-mates
Please list any additional information we need to know.
Submit
As a part of making your pet's visit more enjoyable, we give many treats including cheese and peanut butter. Does your pet, or someone in your family have food allergies?
Yes. Please do not give my pet cheese or peanut butter.
No. You are welcome to treat my pet to their heart's content!
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