Patient Information Form

Owner's Information
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of appointment*

MonthDayYear
Date
Time of appointment*

:HourMinutesAM/PM Option

Patient Information
Pet Name*
Species*
What symptoms brought you in here today? *
please be descriptive. the more information the better
When did your pets symptoms first start?*
Since I first noticed the problem, it has:*

WorsenedStayed the sameImproved
My pet stays mostly:*

IndoorsOutdoorsBoth indoor and outdoor
Have you noticed any of the following:*

CoughingSneezingVomitingDiarrheaNo coughing, sneezing, vomiting, or diarrhea
If yes to any above, please provide details about when it started, how often its happening, and any specific information the vet may need:
Have you noticed any of the following:*

Increased drinkingIncreased urinationIncreased appetiteDecreased or no appetiteDecreased or no thirstBloody urineBloody stoolLoss of consciousnessSeizure activityBruising on bodyWound or laceration on body (mark on image below)Existing or new tumor/lump (mark on image below)None of the above
Please mark the location of the lump or laceration
Please mark the location of the lump or laceration
Does your pet have any chronic illnesses (example: diabetic, cushings, epilepsy, etc.)?*

YesNo
What condition and when was it diagnosed?*
(Example: Diabetic, Cushing,)
Is your pet currently taking any medications, vitamins, supplements?*

YesNo
Please list all medications or supplements given
What type of food does your pet eat (check all that apply)?*

Wet FoodDry FoodWet and Dry MixtureGrain Free DietRaw Food DietHome Cooked DietPeople food or Table Scraps
What brand of food do you feed to your pet?*
Has anything new been added or fed to your pet in the last 2 weeks? If so, what was added?*
Is it possible for your pet to have:*

Eaten garbageIngested toxins (rat bait, ant bait, other known toxic substances)Ingested mushroomsIngested marijuanaChewed any toys that may have been ingestedEating grain free diet for any period of timeIngested any medications not intended for them or at higher doses than was prescribedNone of the above
Is your pet current on vaccines?*

YesNoUnsure
Would you like to update any vaccines that are due?*

YesNoUnsure
Is your pet current on Heartworm Prevention?*

YesNoUnsure
Would you like to update your pet on their Heartworm Prevention?*

YesNoUnsure
Has your pet traveled outside of Utah ?*

YesNo
Are there other pets in the household?*

YesNo
How many additional pets do you have?*
Are any of your other pets showing similar symptoms?*

YesNoUnsure
Are there any images that would help us with our exam today?
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Do you have any specific questions for the vet?*
Be as specific as you can.
Depending on your pets condition the doctor may recommend bloodwork and/or radiographs. These diagnostic tests may be needed to properly diagnose and treat your pet. In an effort to help get you answers quickly we would like to get your pre-approval for some of these services. Please note:
- We will not perform any tests we do not feel are required for diagnosing your pets condition.
- We will call you prior to doing any additional testing.
- Payment will be due at time of service/pick up. You may be asked to leave a deposit if you are dropping off your pet. We do NOT offer payment plans but we work with Care Credit. To apply please visit www.carecredit.com.
  Please select the tests below you approve our team to perform if needed.
My Products
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Doctor consult $60.00
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Quantity

In house bloodwork $170.00
Comprehensive bloodwork including a chemistry panel that may provide indicators of the health and function of your pet’s pancreas, liver, kidney, intestine, thyroid, and many of their other organs and body systems. and a Complete blood count that can detect conditions like anemia and leukemia, and can detect inflammation, blood clotting concerns, and possible infections. Doing this bloodwork same day provides results more quickly than typical lab results, so you can get an answer or diagnosis and decide next steps

Radiographs - X- rays $155.00
Radiographs can be used to detect fractures, abnormalities such as fluid or gas, tumors, bladder stones, injuries, and deformities. Although radiographs may not give enough information to determine the exact cause of your pet's problem, they can help your veterinarian determine which other tests may be needed to make a diagnosis.

Total $0.00
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We would like to take your pets picture!

Would you be willing to allow us to use your pet's pictures on our website or social media pages? If so, please sign the waiver below:
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.
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We would like to take your pets picture!