Patient Visit Form

Patient Visit Form

Please use a new form for each patient during each visit. This will help us keep the most up to date information regarding your pet and their health.
Client Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Appointment Date *

Month Day Year
Date
Pet Name *
Is this a new patient? *

Yes No
Species *
Breed *
Birth date or Approximate Age *
Color *
Reproductive Status *

Male Female Neutered Male Spayed Female
Has your pet been to any other veterinarians? *

Yes No
Name and Phone Number of Previous Veterinarian
Please share a picture of your pet!

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Pictures will not be shared on our website or any social media platform without a consent form. Cancel of
What type of diet are you feeding your pet? *
Does your pet have any food or environmental allergies that you are aware of? *

Yes No
Has your pet had allergy blood work done?

Yes No
What type of Appointment are you here for today? *
Describe your concerns related to this appointment, include duration and location of injury or illness.
Is your pet currently on any medication? *

Yes No
Please list all current medications and when they are given
Does your pet need a refill of any medications today? *

Yes No
Please list any medications that need to be refilled
Would you like to sign up for our home delivery service for food and medications? *

Yes No
Please go to www.sacajweahealthcareforpets.vetsfirstchoice.com to create an account.
By opting in to sign up for our home delivery service you will receive an email from Vets First Choice to create an account if you have not done so already in order to receive your pets food and/or medications. You will also receive emails regarding promotions and your pets food and/or medications. You can unsubscribe to these emails at any time by clicking unsubscribe. Sacajawea Healthcare for Pets will not be able to refund or take in any donated medications from Vets First Choice.
Has your pet had any coughing or sneezing? *

Yes No
How long has this been going on?
Has there been any discharge from the eyes? *

Yes No
What color is the eye discharge?
Has your pet been vomiting? *

Yes No
How long has this been going on?
Please give a short description of the vomit and how often this occurs
Has your pet had diarrhea? *

Yes No
How long has this been going on?
Have you noticed any bloody or tarry stool? *

Yes No
Has your pet traveled outside of the Puget Sound area within the last 6 months? *

Yes No
Please give details of travel (when, where, how long was the stay).
Do you have any concerns regarding your pets ears or skin? *

Ears Skin Both Ears and Skin No
Please give a short description about your concerns with your pets ears and/or skin
Do you have any other concerns you would like to discuss with the veterinarian today? *

Yes No
Please give a short description about your other concerns
Should be Empty: