PATIENT HISTORY FORM EXOTICS

Bergen Veterinary Hospital

1680 TEANECK ROAD

TEANECK, NJ 07666

(201) 837-3470 Fax (201) 353-3400

www.bergenvet.com

DATE:*

Date

SCHEDULED APPOINTMENT DATE AND TIME:*

Date

OWNERS PRINTED ELECTRONIC SIGNATURE:*

PETS NAME:*

PHONE NUMBER(s) WHERE YOU CAN BE REACHED ON THE APPOINTMENT DATE:*

CELL PHONE NUMBER OR EMAIL ADDRESS WHERE A SECURE PAYMENT LINK CAN BE SENT:*

REASON FOR VISIT:*

ADDITIONAL CONCERNS:*

If your pet is visiting Bergen Veterinary Hospital for the first time, all medical records and vaccine histories must be sent before your scheduled appointment to info@bergenvet.com or faxed to 201-353-3400.

FOOD DIET:*

IS YOUR PET HAVING ANY PROBLEMS WITH ANY OF THE FOLLOWING:

EATING:*

DRINKING:*

DEFECATING:*

URINATING:*

COUGHING:*

SNEEZING:*

DIARRHEA:*

VOMITING:*

IF YOU ANSWERED YES TO ANY OF THE PREVIOUS QUESTIONS PLEASE ELABORATE:*

ARE THERE ANY OTHER CONCERNS YOU WOULD LIKE ADDRESSED TODAY:*

VACCINES NEEDED/ UPDATED TODAY:*

WOULD YOU LIKE BLOODWORK DONE TODAY Y/N:*

WE RECOMMEND ALL PETS BE TESTED BI-ANUALLY FOR INTERNAL PARASITES: PLEASE REMEMBER TO BRING IN A FRESH FECAL SAMPLE AT THE TIME OF VISIT. (No more than 24 hours old)

DID YOU BRING A URINE OR FECAL SAMPLE THAT YOU WOULD LIKE SENT OUT TODAY: Y/N*

WOULD YOU LIKE US TO TRIM YOUR PETS NAILS: ($17.00) Y/N:*

ARE THERE ANY MEDICATIONS YOU WOULD LIKE US TO REFILL AT THIS TIME- Y/N: *

IF YES PLEASE LIST NAME OF DRUG, CURRENT DOSING INSTRUCTIONS BEING GIVEN: *

PLEASE CALL BERGEN VETERINARY HOSPITAL AT 201-837-3470 WHEN YOU ARRIVE FOR YOUR VISIT AND A TECHNICIAN WILL MEET YOU OUTSIDE TO PICKUP YOUR PET AND REVIEW THIS FORM WITH YOU.

Due to the COVID-19 pandemic clients are unable to come into the hospital at this time. With the exception of vet tech appointments, all appointments are drop off appointments. Due to possible long wait times, Bergen Veterinary Hospital STRONGLY RECOMMENDS that you do not wait at our facilities for your pet to be finished with their appointment. After your pet is admitted by one of our veterinary technicians, it is best that you go home or run an errand. It is VERY IMPORTANT that Bergen Veterinary Hospital can reach you at all times while your pet is in our facility. PLEASE HAVE YOUR PHONE WITH YOU AT ALL TIMES DURING THE APPOINTMENT IN ORDER TO BE REACHED. Once your pet is examined, you will be called to discuss the doctors findings, treatment plan as needed, and answer any questions you may have. When the appointment is over, you will receive a call from a BVH team member letting you know your pet is ready to be picked up. At that time a secure payment link will be texted or emailed.

Please be reassured that most pets do very well without their owners present. Pets tend to have less anxiety when their owners are not present, mainly for two reasons. 1) Pets can detect when their owners are anxious and in turn this makes them anxious. 2) It is our pets nature to want to protect their owners so they are on high alert when their owners are present.