Patient Information Form

Patient Information Form
*FOR THE SAFETY OF OUR STAFF AND CLIENTS PLEASE ARRIVE WEARING A MASK AND MAINTAIN 6 FOOT DISTANCE AT ALL TIMES*
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Best number to call you in the parking lot during your exam *

Area Code Phone Number
Email *
Date of appointment *

Month Day Year
Date
Time of appointment *

: Hour Minutes AM/PM Option
Please describe your vehicle so we can easily find you in the parking lot *
Pet Name *
Species *

Canine Feline
My pet stays mostly: *

Indoors only Outdoors only Both indoor and outdoor
What are we seeing your pet for today? Please choose all that apply

Wellness exam Illness Injury/ limping Laceration, Lump
What symptoms brought you in here today? *
please be descriptive. the more information the better
When did your pets symptoms first start? *
Please mark the location of the lump or laceration
Please mark the location of the lump or laceration
Since I first noticed the problem, it has: *

Worsened Stayed the same Improved
Have you noticed any of the following: *

Coughing Sneezing Vomiting Diarrhea none of the above
If vomiting, how long and what does vomiting look and smell like?
If diarrhea, how long?
Is there any of the following in the diarrhea: *

Blood Mucus Accidents in the house none of the above
Have you noticed any of the following: *

Increased drinking Increased urination Loss of consciousness Seizure activity Bruising Bleeding Bloody urine decreased appetite decreased thirst increased appetite none of the above
Please Explain:
Does your pet have any chronic illnesses? (example: Diabetic, cushings, epilepsy) *

Yes No
What condition and when was it diagnosed? *
(Example: Diabetic, Cushing,)
Is your pet currently taking any medications, vitamins, supplements? please give strength, dose , and when last dose was given. *

Yes No
Please List all medications and supplements and dose
When was the last dose given
Is your pet current on vaccines? *

Yes No Unsure
Would you like to update vaccines today
Is your pet current on Heartworm Prevention? *

Yes No
What pet diet do you give your pet? *
Do they get table scraps? *
Has your pet travel outside of Utah ?

Yes No
Please explain: *
Location, frequency, when
Are there other pets in the household? *

Yes No
number of additional pets
Are they showing any similar signs?
Do you have questions for the vet? *
There may be rare instances where the veterinarian requests that one client may enter the clinic (Euthanasia, medication administeration demonstration, severe behaviorally challenging consultations, etc.). During those rare instances we will require that the client that comes will be required to wear a mask that covers both their nose and mouth, sanitize their hands (provided at entry), and maintain a 6 foot distance from the staff at all times.

PLEASE NOTE - WE CANNOT PROVIDE ANY MASKS DUE TO THE PPE SHORTAGE SO PLEASE COME PREPARED WITH YOUR OWN MASK. IF YOU DO NOT HAVE A MASK YOU WILL NOT BE PERMITTED IN THE CLINIC AND MAY BE ASKED TO RESCHEDULE YOUR APPOINTMENT.

We sincerely appreciate your cooperation.
*

I understand and agree to the above statement
We would like to take your pets picture.

would you be willing to allow us to use your pets pictures. Please sign the release below and you could see your pet on our website or social media page.
Do you give permission to Midvalley Animal Clinic to use any photographs taken of your pet, in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become property of Midvalley Animal Clinic and will not be returned. I hereby authorize Midvalley Animal Clinic to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing thier programs or for any other lawful purpose.

In signing this consent, I give authorization to use my pet’s name and information as printed below.
Name

First Name Last Name
Signature

Clear
Should be Empty:

Patient Information Form

*FOR THE SAFETY OF OUR STAFF AND CLIENTS PLEASE ARRIVE WEARING A MASK AND MAINTAIN 6 FOOT DISTANCE AT ALL TIMES*

We would like to take your pets picture.

FOR THE SAFETY OF OUR STAFF AND CLIENTS PLEASE ARRIVE WEARING A MASK AND MAINTAIN 6 FOOT DISTANCE AT ALL TIMES