Appointment Intake Form

Appointment Intake Form

Please take a moment to answer the following questions as best as you can prior to your pet’s appointment. Doing this will help expedite the appointment. Please make sure to bring your CELL PHONE and turn the volume up for curbside appointments.
Starting 5/1/23: Due to our small hospital, Dr. Shuman will see in person appointments Tuesday and Thursday and Dr Hall will be seeing appointments on Wednesday. All drop offs and scheduled appts with a technician will be curbside. Only one person will be allowed in the hospital for in person appointments, masks are optional.*

I Understand
Please take a moment to read this COVID Questionnaire:
Have you or any one in your house hold been sick with the following symptoms?:
- Fever, cough, sore throat, headache, loss of smell or taste or any other flu-like symptoms.
- Or been diagnosed with COVID in the last 14 days?
If yes to either, Please contact WAH BEFORE your appointment.

If you are sick with the above symptoms, please have someone else that is NOT sick bring the pet to the appointment. If that is not an option, then we will do our best to help your pet over the phone or with medication.
Please put your response to the above COVID questionnaire*

I am healthy!I am under the weather, but someone else will bring my petI am under the weather and I don't have anyone to bring my pet
Which Pet Insurance do you have for your pet? See bottom of page for more information about pet insurance.
Pet Name*
Client Name*

First NameLast Name
Please list the best PHONE NUMBER to be called for your appointment (include area code, please)*
Email
example@example.com
Has any of your personal information changed? Name, Address, phone, email... Please update below, otherwise leave blank. New clients please go to this link and fill out a new client registration form prior to your appointment. https://scwah.com/new-client-registration-form/
Today's Date*

MonthDayYear
Date
Appointment Date*

MonthDayYear
Date
Please list the reason for your appointment or if there are any other health concerns: Please be as detailed as possible.
Has your pet had any of the following symptoms? If so, include duration and frequency*

CoughingSneezingVomitingDiarrheaNone of the above
If any of the above, please write specific details of duration and frequency
Any changes in your pet’s energy or appetite?
What flea/tick/heartworm prevention is your pet on?*

CredelioSimparicaInterceptor PlusHeartgard PlusTrifexisComfortisI need a refill
Is your pet on any other medications? Please list.
Would you like to update vaccines if your pet is healthy enough?
What Brand and flavor of your pet’s food?*
If you are bringing in a cat; is it indoor, outdoor or both?
Do you have any additional requests while your pet is in the hospital?
If you are unsure if your pet is due for a fecal test, please feel free to text, call or email us to check. Otherwise feel free to bring a sample and if it is not due we will dispose of it for you.

831-427-2239- text or call

frontdesk@scwah.com email
If this is your first visit, please attach any medical and vaccine records here.

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Please verify that you are human*
Should be Empty: