Pre-Appointment Patient Information Form

Patient & History Form

Pre-Appointment Form
Pet's name*
*Please only fill this out if you have a scheduled appointment.

This form is for new* AND established patients!

CHECK-IN PROCESS:
- For the comfort and safety of all our patients, we check in every appointment curbside over the phone!
  Please park in front of or close to the clinic, remain in your car, and give us a call to check in. A member of our team will come out to greet you and your pet and welcome you inside. Keeping our lobby clear of people and animals helps to keep everyone's stress level down!
- Please do not wait by the entrance or crowd the sidewalk. Some of our patients are fearful or people/dog reactive.
- Please secure cats safely in a carrier and keep your dog on a leash at all times. We kindly ask that prong and/or electric collars be removed before entering our facility.
*If you are a new client and you have copies of your pet's medical records, or are an established client with updated records for your pet from a different clinic, please email them to us before your appointment at hello@brooklynyardvet.com or you can upload them at the bottom of this form.

Thank you!
Your name*

First NameLast Name
For existing clients, has any of your personal information changed (ie address, phone number). If so, please update any information below:
Appointment Date *

MonthDayYear
Date
My pet is a:

DogCat

My pet is a cat
Please describe the reason for your appointment today. **PLEASE BE AS DETAILED AS POSSIBLE**, even for wellness exams! Please include any pertinent history of any problems or any questions you may have:*
Please describe any VETERINARY SPECIFIC behavior concerns for your cat that we should be aware of:*
Ex: Likes to hide, afraid of being held, does not like paws touched etc.
Please list all medications and supplements your cat is taking - this INCLUDES flea/heartworm/parasite prevention. **Please include the name, strength, amount and frequency:***
Do you need medication refills? **Please read our prescription policy at the bottom of the page if you purchase medication outside of our clinic***
**We do not process orders from any online suppliers or outside pharmacies via phone, email, or fax. We will provide you with a written prescription for medications filled outside of our clinic.
How much time does your cat spend outside?*
Are there any other animals in the house?
Does your cat have access to Raw food or treats?*
Any changes in litterbox habits? Feel free to tell us about your litter box set up! How many, where are they located, covered or uncovered and what kind of litter?*
If we haven't seen your cat before, or recently, have you been seen anywhere else for veterinary care (including emergency facilities)? Please list the name of ALL veterinary clinics that your cat has been seen at previously:
Please list ALL hospitals - including specialty and ER hospitals
Has your cat had any previous health issues or major surgeries we should be aware of?
Does your cat have an Instagram? Enter their username below!
What pet insurance company do you use for your cat?*
If your pet has no insurance policy, please type "NONE"
If applicable, please provide your cat's insurance policy number:*
Please type in your pet's insurance policy number, this helps us to more efficiently process claims. If no insurance, please type "N/A"
Are you interested in receiving a free 30-day trial of Trupanion Pet Insurance with your exam?*

YesNoMaybe (please let us know at your appointment)
Upload any medical records that you may have here!

Upload Records
We are happy to request medical records on your behalf - please list ALL hospitals above! Cancelof
PRESCRIPTION POLICY REMINDER:

Brooklyn Yard Veterinary Hospital WILL NOT process (phone, email, fax etc.) prescriptions to or from outside and online pharmacies (with the only exception being for medications that need to be compounded).

Clients who opt to obtain their pet's medication through these avenues will need to pick up a physical written prescription at our hospital.

Please refer to our prescription policy on our website for more information: Brooklyn Yard Veterinary Hospital Prescription Policy.
Please check off ALL of the following to acknowledge you understand our policies:*

I understand that if I am 10+ minutes late to my appointment then I may be asked to reschedule.I agree to have my cat secured in a carrier before entering the clinic.

My pet is a dog
Please describe the reason for your appointment today. **PLEASE BE AS DETAILED AS POSSIBLE**, even for wellness exams! Please include any pertinent history of any problems or any questions you may have:*
Please describe any VETERINARY SPECIFIC handling/behavior concerns for your dog that we should be aware of, such as paw phobic/noise sensitivities/animal reactivity/fear related reactivity etc:*
PLEASE READ - If we determine that the scheduled time cannot safely and appropriately accommodate your dogs needs in a veterinary setting, then we will contact you to reschedule. Our veterinarians will not have adequate time to discuss in-depth behavior issues if you are not scheduled for a specific behavior consult.
Please list all medications and supplements your dog is taking - this INCLUDES flea/heartworm/parasite prevention. **Please include name, strength, amount, and frequency:***
Do you need medication refills? Please read our prescription policy at the bottom of the page if you purchase medication outside of our clinic***
**We do NOT process orders from any online suppliers or outside pharmacies via phone, email, or fax. We will provide you with a written prescription for medications filled outside of our clinic.
Tell us about your dog's lifestyle (hiking, dog parks, daycare, beach, river etc.)*
How many other animals are in your household?
What are you feeding your dog? Please list the brand/type of food and amount and include treats:*
If we haven't seen your dog before, or recently, have you been seen anywhere else for veterinary care (including emergency facilities)? Please list the names of ALL veterinary facilities that they have been seen at previously:
Please list ALL speciality and ER clinics that your pet has been seen at.
Has your dog had any previous health issues or major surgeries we should be aware of?
Does your dog have an Instagram? Enter their username below!
What pet insurance company do you use for your dog?*
If your pet has no insurance policy, please type "NONE"
If applicable, please provide your dog's insurance policy number:*
Please type in your pet's insurance policy number, this helps us to more efficiently process claims. If no insurance, please type N/A
Are you interested in receiving a free 30-day trial of Trupanion Pet Insurance with your exam?*

YesNoMaybe (please ask us more info at your appointment!)
Upload any medical records that you may have here!

Upload Records
We are happy to request medical records on your behalf - please list ALL hospitals above! Cancelof
PRESCRIPTION POLICY REMINDER:

Brooklyn Yard Veterinary Hospital WILL NOT process (phone, email, fax etc.) prescriptions to or from outside and online pharmacies (with the only exception being for medications that need to be compounded).

Clients who opt to obtain their pet's medication through these avenues will need to pick up a physical written prescription at our hospital.
Please refer to our prescription policy on our website for more information: Brooklyn Yard Veterinary Hospital Prescription Policy.
Please check off ALL of the following to acknowledge you understand our policies:*

I understand that if I am 10+ minutes late to my appointment then I may be asked to reschedule.I agree to have my dog safely leashed before entering the clinic.I understand that prong collars, electronic collars, and all other aversive tools are prohibited inside BYVH.
Should be Empty:

Patient & History Form

*Please only fill this out if you have a scheduled appointment.

This form is for new* AND established patients!

CHECK-IN PROCESS:

**This form is for new* AND established patients!**