"Helping pets [and their people] live longer, healthier and happier lives [together]."
Patient Check-In Form
Please fill out and return prior to your pet's scheduled appointment
Client (Human) Name
Patient (Pet) Name
Alternative Phone Number (Where you may be reached during your pet's appointment)
Street Address Line 2
State / Province
Postal / Zip Code
Reason For Appointment (Please select the most accurate):
Annual Exam (Healthy Pet)
Annual Exam (I have concerns for my Pet)
My Pet is Sick or Injured
Drop-Off Appointment (I'm leaving my pet)
Outpatient (Nail Trim, Anal Gland Expression)
Illness Recheck (with Veterinarian)
Surgery Recheck (with Veterinarian)
Have you noticed any changes in your pets Eating and Drinking patterns within the last 7-14 days?
Has your pet experienced any Coughing or Sneezing within the last 7-14 days?
Has your pet experienced any Vomiting or Diarrhea in the last 7-14 days?
Have you noticed any changes in your pets "bathroom behavior" (Urinating/Defecating) within the last 7-14 days?
Has your pet displayed signs of itchiness in the last 7-14 days? (Scratching, licking, chewing, etc.) If so, please grade your pet's itch on a level of 1-10 with 10 being the itchiest.
If you answered "Yes" to any of the above questions, please provide as much detail as possible: (When was the behavior/concern first observed? Has it gotten better or worse? Have you provided any "at home" therapy or given your pet anything to try and help? Is this the first time you've ever observed this?)
Please list any additional concerns, information or requests you would like your Medical Provider Team to be aware of (as it pertains to your pet's care. This includes additional services such as Nail Trims and Anal Gland Expressions while your pet is in our care):
Do you need any refills? (Medication, Diet, etc.)
If refills needed, please list Medication or Diet name: (Providing as much information as possible allows us to ensure adequate stock levels and proactively prepare your items.)
By signing below, I hereby authorize the team of Licensed Veterinarian's and Technician's at Portland Veterinary Wellness Center to examine my pet and provide necessary medical treatments as it pertains to their immediate health. (This includes providing pain management for my pet if it is displaying clinical signs of discomfort while under care at Portland Veterinary Wellness Center.)
Should be Empty: