Veterinary Intake Form

Please do not drive away after we take your pet into the hospital unless a veterinary staff member asks you to drop them off. If you leave the premise without informing a staff member, a boarding fee for the day may apply to your pet's charges.
Your Full Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
If you would like to attach your pet's previous history, please do so here.

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Is there another hospital we need to call for records?
If you would like to attach a photo of your pet for our files, please do so here.

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Best Phone Number for Today's Appointment *

Area Code Phone Number
Patient's Name *
Patient's Sex *

Male Female Male/Neutered Female/Spayed Unknown
Primary Reason for Appointment/Concerns *
If the patient is a cat, where do they spend most of their time?

Indoors Outdoors Both
If you have a pocket pet/reptile, please describe their cage or enclosure:
Is the patient on Heartworm Prevention? *

Yes No I'm not sure
Is the patient on flea/tick medication? *

Yes No I'm not sure
What type/brand of food does the patient eat? How much do you feed? *
Patient's Energy Level *

Normal Increased Decreased
Patient's Appetite *

Normal Increased Decreased
Drinking Water/Intake *

Normal Increased Decreased
Is the patient coughing? *

Yes No I'm not sure
Is the patient sneezing? *

Yes No I'm not sure
Is the patient vomiting? *

Yes No I'm not sure
Does the patient have diarrhea? *

Yes No I'm not sure
Patient's Urination *

Normal Increased Decreased Blood Present Dark Cloudy Straining to Urinate Strong/Foul Odor
Any previous Patient history we should be aware of?
Any additional information that you would like the Veterinarian to be aware of?
Should be Empty:

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